Specialty pharmacy updates - December 2022

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) along with our affiliate HealthKeepers, Inc., are listed below.

 

Prior authorization clinical review of nononcology use of specialty pharmacy drugs is managed by our 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 prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of oncology will still require preservice clinical review by AIM. This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Inclusion of the 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.

 

Step therapy updates

 

Clinical Criteria ING-CC-0182 currently has a step therapy preferring Ferrlecit^®, Infed^®, and Venofer^®.

 

Effective for dates of service on and after March 1, 2023, the status of Infed in current criteria documents will be changing in our existing specialty pharmacy medical step therapy review process. This update is to notify that Infed will change to non-preferred.

 

Also, effective for dates of service on or after December 1, 2022, Feraheme^® (ferumoxytol) will change to preferred for both brand and generic.

 

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

 

Clinical Criteria	Status	Drug	HCPCS or CPT® code(s)
ING-CC-0182	Nonpreferred	Infed (iron dextran)	J1750
ING-CC-0182	Nonpreferred	Injectafer® (ferric carboxymaltose)	J1439
ING-CC-0182	Nonpreferred	Monoferric® (ferric derisomaltose)	J1437
ING-CC-0182	Preferred	Feraheme (ferumoxytol)	Q0138
ING-CC-0182	Preferred	Ferrlecit (sodium ferric gluconate/sucrose complex)	J2916
ING-CC-0182	Preferred	Venofer® (iron sucrose)	J1756

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc.

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