Prior authorization updates for specialty pharmacy

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

Effective for dates of service on and after November 1, 2021, the following specialty drug codes from current or new clinical criteria documents will require prior authorization.

 

Please note, inclusion of national drug code (NDC) on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

Visit the Clinical Criteria website to search for the specific clinical criteria listed below. 

 

Clinical Criteria	HCPCS or CPT® code(s)	Drug	Drug classification
ING-CC-0170	J1823	Uplizna	Immunosuppressive agents
ING-CC-0172	J3490, J3590, C9071	Viltepso	Muscular dystrophies
ING-CC-0173	J3490, J3590	Enspryng	MISC conditions
ING-CC-0174	J3490, J3590, C9399	Kesimpta	Multiple sclerosis
ING-CC-0168	J9999, C9073	Tecartus	CAR-T
ING-CC-0171	J9223	Zepzelca	Cancer
ING-CC-0169	J9316	Phesgo	Cancer
ING-CC-0175	J9015	Proleukin	Cancer
ING-CC-0176	J9032	Beleodaq	Cancer
ING-CC-0178	J9262	Synribo	Cancer
ING-CC-0177	J3304	Zilretta	Osteoarthritis
ING-CC-0002	Q5122	Nyvepria	Blood cell deficiency
ING-CC-0038	J3110	Forteo	Osteoporosis

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

 

AVAPEC-3051-21