Anthem Blue Cross and Blue Shield | CommercialMarch 27, 2025
Specialty pharmacy updates — April 2025
Your patients may be receiving medications listed in the tables below without preapproval. As of July 1, 2025, you may need to request a preapproval review to ensure your patients’ continued use of these medications. Including the National Drug Code (NDC) on your claim will help us process claims more quickly for drugs billed with a not otherwise classified (NOC) code.
Preapproval updates
Effective for dates of service on or after July 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our preapproval review process.
Access our Clinical Criteria to view the complete information for these preapproval updates.
Clinical Criteria | Drug | HCPCS or CPT® code(s) |
CC-0272 | Aucatzyl (obecabtagene autoleucel) | C9399, J9999 |
CC-0274* | Bizengri (zenocutuzumab-zbco) | C9399, J9999 |
CC-0041 | Bkemv (eculizumab-aeeb) | Q5139 |
CC-0058 | Bynfezia Pen (octreotide acetate) | C9399, J3490 |
CC-0041 | Epysgli (eculizumab-aagh) | J3590 |
CC-0149 | Hympavzi (marstacimab-hncq) | C9399, J3590 |
CC-0063 | Imuldosa (ustekinumab-srlf) | J3590 |
CC-0063 | Otulfi (ustekinumab-aauz) | J3590 |
CC-0063 | Pyzchiva IV (ustekinumab-ttwe) | Q9997 |
CC-0063 | Pyzchiva SC (ustekinumab-ttwe) | Q9996 |
CC-0063 | Selarsdi (ustekinumab-aekn) | Q9998 |
CC-0128* | Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) | C9399, J9999 |
CC-0276 | Tryngolza (olezarsen) | C9399, J3490 |
CC-0273* | Vyloy (zolbetuximab-clzb) | C9399, J9999 |
CC-0063 | Yesintek (ustekinumab-kfce) | J3590 |
CC-0275* | Ziihera (zanidatamab-hrii) | C9399, J9999 |
*Carelon Medical Benefits Management manages oncology use.
Note: Preapproval requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on or after July 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
Clinical Criteria | Status | Drug | HCPCS or CPT code(s) |
CC-0063 | Non-preferred | Imuldosa (ustekinumab-srlf) | J3590 |
CC-0063 | Non-preferred | Otulfi (ustekinumab-aauz) | J3590 |
CC-0063 | Non-preferred | Pyzchiva IV (ustekinumab-ttwe) | Q9997 |
CC-0063 | Non-preferred | Pyzchiva SC (ustekinumab-ttwe) | Q9996 |
CC-0063 | Non-preferred | Selarsdi (ustekinumab-aekn) | Q9998 |
CC-0063 | Non-preferred | Wezlana IV (ustekinumab-auub) | Q5138 |
CC-0063 | Non-preferred | Wezlana SC (ustekinumab-auub) | Q5137 |
CC-0072 | Non-preferred | Ahzantive (aflibercept-mrbb) | J3590, C9399 |
CC-0072 | Non-preferred | Enzeevu (aflibercept-abvz) | J3590, C9399 |
CC-0072 | Non-preferred | Opuviz (aflibercept-yszy) | J3590, C9399 |
CC-0072 | Non-preferred | Yesafili (aflibercept-jbvf) | J3590, C9399 |
CC-0072 | Preferred | Pavblu (aflibercept-ayyh) | J3590, C9399 |
Note: Preapproval requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on or after July 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
Clinical Criteria | Drug | HCPCS or CPT code(s) |
CC-0274 | Bizengri (zenocutuzumab-zbco) | C9399, J9999 |
CC-0058 | Bynfezia Pen (octreotide acetate) | C9399, J3490 |
CC-0063 | Imuldosa (ustekinumab-srlf) | J3590 |
CC-0063 | Otulfi (ustekinumab-aauz) | J3590 |
CC-0063 | Pyzchiva IV (ustekinumab-ttwe) | Q9997 |
CC-0063 | Pyzchiva SC (ustekinumab-ttwe) | Q9996 |
CC-0063 | Selarsdi (ustekinumab-aekn) | Q9998 |
CC-0276 | Tryngolza (olezarsen) | C9399, J3490 |
CC-0063 | Yesintek (ustekinumab-kfce) | J3590 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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PUBLICATIONS: April 2025 Provider Newsletter
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