Specialty pharmacy updates effective December 1, 2022

Specialty pharmacy updates for of Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are listed below.

 

Prior authorization clinical review of non-oncology 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 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.

 

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

 

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

 

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.

 

Prior authorization updates

 

Effective for dates of service on and after December 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	Drug	HCPCS or CPT® code(s)
ING-CC-0217	Amvuttra™ (vutrisiran)	J3490, J3590
ING-CC-0218	Xipere® (triamcinolone acetonide injectable suspension)	J3299

 

Note: Oncology use is managed by AIM.

 

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

 

Quantity limit updates

 

Effective for dates of service on and after December 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-0217	Amvuttra (vutrisiran)	J3490, J3590
ING-CC-0218	Xipere (triamcinolone acetonide injectable suspension)	J3299

 

Note: Oncology use is managed by AIM.

 

* 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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