Prior authorization updates for specialty pharmacy are available

Prior authorization updates

 

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

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. 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, 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 would apply 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-0095	J9041	Velcade (Bortezomib)
*ING-CC-0095	J9044	Bortezomib
*ING-CC-0093	J9171	Docetaxel
*ING-CC-0181	J3490	Veklury

 

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

 

Step therapy updates

 

Update on Ocrevus step therapy notification

 

Ocrevus will still be non-preferred as noted below, but please note that the step therapy criteria have been updated since the last publication. 

 

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 step therapy drug list.   

 

For Anthem Blue Cross and Blue Shield and 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 would apply 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-0011	Non-preferred	Ocrevus	J2350

 

 

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.

 

• The NOC codes, J3490, J3590 and C9399 are valid codes for Kesimpta. The code J9302 is not a valid code for the drug Kesimpta.

 

915-0120-PN-VA