Anthem prior authorization updates for specialty pharmacy are available

Prior authorization updates

 

Effective for dates of service on and after October 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with the Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.

Please note, inclusion of NDC code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

Access the Clinical Criteria information.

For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health_® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0038	J3110	Bonsity
ING-CC-0162	J3490 J3590	Tepezza
ING-CC-0163	J3490 C9399	Durysta

 

Step therapy updates

 

Effective for dates of service on and after October 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

 

Access the Clinical Criteria information with step therapy(ies).

 

For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health_® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).

Clinical Criteria	Status	Drug(s)	HCPCS Codes
ING-CC-0072	Preferred	Avastin	J9035, C9257
ING-CC-0072	Preferred	Mvasi	Q5107
ING-CC-0072	Preferred	Zirabev	Q5118
ING-CC-0072	Preferred	Eylea	J0178
ING-CC-0072	Non-preferred	Lucentis	J2778
ING-CC-0072	Non-preferred	Macugen	J2503
ING-CC-0072	Non-preferred	Beovu	J0179

 

CORRECTION: June 2020 step therapy update on clinical criteria ING-CC-0003:

 

Panzyga has been non-preferred for ING-CC 0003 since 2018.

 

In the June 2020 Provider News edition, we published information regarding Panzyga to be effective September 1, 2020. This was published in error.

 

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