Anthem prior authorization updates for specialty pharmacy are available

Prior authorization updates

 

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Anthem in Virginia 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 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.

 

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 and are shown in italics in the table below.

 

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

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0170	J3590, C9399	Uplizna
ING-CC-0172	J3490, J3590, C9399	Viltepso
ING-CC-0173	J3490, J3590	Enspryng
ING-CC-0174	J3490, J3590, C9399	Kesimpta
ING-CC-0168	J3590, J9999, J3490	Tecartus
*ING-CC-0171	J3490, J3590, J9999	Zepzelca
*ING-CC-0169	J3490, J3590, J9999, C9399	Phesgo
*ING-CC-0175	J9015	Proleukin
*ING-CC-0176	J9032	Beleodaq
*ING-CC-0178	J9262	Synribo
*ING-CC-0177	J3304	Zilretta
ING-CC-0015	J3490	Milprosa Vaginal System
*ING-CC-0100	C9065	Istodax
ING-CC-0038	J3110	Forteo
*ING-CC-0002	J3590	Nyvepria

 

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

 

Step therapy updates

 

Effective for dates of service on and after January 1, 2021, 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 related to Step Therapy.

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 and are shown in italics in the table below.

 

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

 

Clinical Criteria	Status	Drug(s)	HCPCS Code(s)
*ING-CC-0002	Preferred	Neulasta	J2505
*ING-CC-0002	Preferred	Udenyca	Q5111
*ING-CC-0002	Non-preferred	Fulphila	Q5108
*ING-CC-0002	Non-preferred	Ziextenzo	Q5120
*ING-CC-0002	Non-preferred	Nyvepria	J3590

 

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

 

676-1020-PN-VA