Specialty pharmacy updates are available

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

 

For Anthem 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.

 

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

Please note that 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 the Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.

 

Site of care updates

 

Effective for dates of service on and after January 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.

 

Access our Clinical Criteria to view the complete information for these site of care updates.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0062	Q5121	Avsola
*ING-CC-0081	J0584	Crysvita
*ING-CC-0162	J3241	Tepezza

* Non-oncology use is managed by the medical specialty drug review team.

 

Quantity limit updates

 

Effective for dates of service on and after January 1, 2022, 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)
ING-CC-0009	Lemtrada	J0202
ING-CC-0011	Ocrevus	J2350
ING-CC-0014	Avonex	J1826
		Q3027
	Betaseron	J1830
	Copaxone	J1595
	Extavia	J1830
	Glatopa	J1595
	Plegridy	J3590
		C9399
	Rebif	J1826
		Q3028
ING-CC-0020	Tysabri	J2323
ING-CC-0029	Dupixent	J3490
		J3590
ING-CC-0038	Bonsity	J3110
	Forteo	J3110
	Tymlos	C9399
		J3490
ING-CC-0042	Siliq	C9399
		J3490
		J3590
	Taltz	C9399
		J3490
		J3590
ING-CC-0048	Spinraza	J2326
ING-CC-0062	Avsola	Q5121
	Erelzi	J3590
	Eticovo	J3590
ING-CC-0066	Kevzara	C9399
		J3590
		J3490
ING-CC-0075	Riabni	Q5123
ING-CC-0077	Palynziq	C9399
		J3590
ING-CC-0082	Onpattro	J0222
ING-CC-0156	Reblozyl	J0896
ING-CC-0159	Scenesse	J7352
ING-CC-0160	Vyepti	J3032
ING-CC-0162	Tepezza	J3241
ING-CC-0163	Durysta	J7351
ING-CC-0170	Uplizna	J1823
ING-CC-0172	Viltepso	J1427
ING-CC-0173	Enspryng	J3490
		J3590
ING-CC-0174	Kesimpta	C9399
		J3490
		J3590
ING-CC-0177	Zilretta	J3304
ING-CC-0181	Veklury	J3490
ING-CC-0183	Sogroya	J3590
ING-CC-0185	Oxlumo	J0224
ING-CC-0188	Imcivree	J3490
		J3590
ING-CC-0193	Evkeeza	J3490
		C9079
ING-CC-0194	Cabenuva	J3490
		C9077

 

1338-1021-PN-VA