Clinical Criteria and prior authorization updates for specialty pharmacy are available

Anthem expands specialty pharmacy prior authorization list

 

Effective for dates of service on and after December 1, 2019, the following non-oncology specialty pharmacy codes from current clinical criteria will be included in our prior authorization review process.

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

 

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 prior authorization clinical review by AIM Specialty Health® (AIM), a separate company.

 

Clinical Criteria	HCPCS or CPT Code(s)	NDC Code(s)	Drug
ING-CC-0031	J3490	71879-0136-01	Yutiq™
ING-CC-0003	J3490 J3590 C9399	68982-0810-01 68982-0810-02 68982-0810-03 68982-0810-04 68982-0810-05 68982-0810-06	Cutaquig®
ING-CC-0003	J1599	69800-0250-01	Asceniv™

 

Clinical Criteria updates for specialty pharmacy

 

Clinical Criteria ING-CC-0061 addresses the use of gonadotropin releasing hormone analogs for the treatment of non-oncologic indications.

 

Effective for dates of service on and after December 1, 2019, the use of Zoladex for the treatment of endometriosis will be limited to 6 months.   Access the Clinical Criteria information.