Prior authorization updates for specialty pharmacy are available

Prior authorization updates

 

Effective for dates of service on and after February 1, 2021, 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 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-0127	J9999, C9399	Darzalex Faspro

 

* 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 February 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 Codes
ING-CC-0160	Non-preferred	Vyepti	J3032
ING-CC-0160	Non-preferred	Vyepti	C9063
ING-CC-0011	Non-preferred	Ocrevus	J2350

 

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

 

Correction to a prior authorization update

 

In the October 2020 edition of Provider News, we published a prior authorization update regarding clinical criteria ING-CC-0174 on the drug Kesimpta.

 

• One HCPCS code has been added, J9302. This is the valid code for the drug Kesimpta.

 

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