Specialty pharmacy updates are available (effective for dates of service on and after February 1, 2022)

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield are listed below. These updates are effective for dates of service on and after February 1, 2022.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem Blue Cross and Blue Shield’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_® (AIM), a separate company.

 

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.

 

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 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.

 

Prior authorization updates

 

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

 

Access our Clinical Criteria to view the complete information for these prior authorization updates.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0096**	J3590	Rylaze
ING-CC-0167**	Q5119	Ruxience
ING-CC-0167**	Q5115	Truxima
ING-CC-0202	J3490 J3590	Saphnelo
ING-CC-0203	J3490 J3590	Ryplazim

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

** Oncology use is managed by AIM.

 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

Step therapy updates

 

Effective for dates of service on and after February 1, 2022, 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. 

 

Clinical Criteria	Status	HCPCS or CPT Code(s)	Drug
ING-CC-0075*	Preferred	J9312	Rituxan
		Q5123	Riabni
	Non-preferred	Q5119	Ruxience
		Q5115	Truxima
ING-CC-0167**	Preferred (no prior authorization or step therapy required)	J9312	Rituxan
		Q5123	Riabni
	Non-preferred	Q5119	Ruxience
		Q5115	Truxima

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

** Oncology use is managed by AIM.

 

Access our Clinical Criteria to view the complete information for these step therapy updates.

 

Quantity limit updates

 

Effective for dates of service on and after February 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	HCPCS or CPT Code(s)	Drug
ING-CC-0081	J0584	Crysvita
ING-CC-0202	J3490 J3590	Saphnelo

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

** Oncology use is managed by AIM.

 

1389-1121-PN-VA