Anthem prior authorization updates for specialty pharmacy are available

Quantity limit updates

 

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

 

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), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0044	J1428	Exondys 51
ING-CC-0058	J2354	Bynfezia
ING-CC-0072	J0179	Beovu
ING-CC-0075	Q5119	Ruxience
ING-CC-0152	J1429	Vyondys 53
ING-CC-0153	C9053	Adakveo

 

* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.

Clinical criteria updates

 

Effective for dates of service on and after November 1, 2020, the following clinical criteria document was revised and might result in services that were previously covered but may now be found to be not medically necessary in our prior authorization review process.

 

Acess the Clinical Criteria information.

 

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.

 

• ING-CC-0003 Immunoglobulins

 

Updated medical necessity criteria for myasthenia gravis to include specific drug failures and chronic inflammatory demyelinating polyneuropathy to include requirements regarding disease duration, specific electrodiagnostic criterion, and objective measures for continuation.

 

Correction to a prior authorization update

 

In the May 2020 edition of Provider News, we published a prior authorization update regarding clinical criteria ING-CC-0157 on the drug Padcev.

 

• One HCPCS code, J9309, was listed in error. This is not a valid code for the drug Padcev.

 

• One HCPCS code has been added, J9999. This is a valid code for the drug Padcev.

 

581-0820-PN-VA