Specialty pharmacy updates effective February 1, 2023

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

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’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, 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, and 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 (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, 2023, 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-0002*	Fylnetra (pegfilgrastim-pbbk)	J3590
ING-CC-0002*	Rolvedon (eflapegrastim-xnst)	C9399, J3490, J3590
ING-CC-0002*	Stimufend (pegfilgrastim-fpgk)	C9399, J3490, J3590
ING-CC-0072	Cimerli (ranibizumab-cqrn)	J3590
ING-CC-0220	Xenpozyme (olipudase alfa)	C9399, J3490, J3590
ING-CC-0221	Spevigo (spesolimab-sbzo)	C9399, J3490, J3590

* Oncology use is managed by AIM.

 

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

 

Site of care updates

 

Effective for dates of service on and after February 1, 2023, 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	Drug	HCPCS or CPT code(s)
ING-CC-0065	Advate (factor viii (antihemophilic factor, recombinant))	J7192
ING-CC-0065	Adynovate (factor vii)	J7207
ING-CC-0065	Afstyla (antihemophilic factor (recombinant) single chain))	J7210
ING-CC-0065	Alphanate (antihemophilic factor viii)	J7186
ING-CC-0065	Eloctate (recombinant antihemophilic factor)	J7205
ING-CC-0065	Esperoct (factor viii recombinant, glycopegylated)	J7204
ING-CC-0065	factor viii, anti-hemophilic factor (porcine)	J7191
ING-CC-0065	Hemlibra (emicizumab-kxwh)	J7170
ING-CC-0065	Hemofil M ((factor viii) human plasma-derived)	J7190
ING-CC-0065	Humate-P (antihemophilic factor viii)	J7187
ING-CC-0065	Jivi (factor viii, recombinant, pegylated-aucl)	J7208
ING-CC-0065	Koate DVI ((factor viii) human plasma-derived)	J7190
ING-CC-0065	Kogenate-FS (factor viii (antihemophilic factor, recombinant))	J7192
ING-CC-0065	Kovaltry (factor viii (antihemophilic factor, recombinant))	J7211
ING-CC-0065	Novoeight (factor viii (antihemophilic factor, recombinant))	J7182
ING-CC-0065	Nuwiq (factor viii (antihemophilic factor, recombinant))	J7209
ING-CC-0065	Obizur (antihemophilic factor viii (recombinant))	J7188
ING-CC-0065	Recombinate (factor viii (antihemophilic factor, recombinant))	J7192
ING-CC-0065	Vonvendi (von willebrand factor)	J7179
ING-CC-0065	Wilate (antihemophilic factor viii)	J7183
ING-CC-0065	Xyntha (factor viii (antihemophilic factor, recombinant))	J7185
ING-CC-0065	Xyntha Solofus (factor viii (antihemophilic factor, recombinant))	J7185
ING-CC-0148	AlphaNine SD (coagulation factor ix (human))	J7193
ING-CC-0148	Alprolix (recombinant coagulation factor ix)	J7201
ING-CC-0148	Benefix (factor ix recombinant)	J7195
ING-CC-0148	Idelvion (factor ix)	J7202
ING-CC-0148	Ixinity (factor ix)	J7195
ING-CC-0148	Mononine (coagulation factor ix (human))	J7193
ING-CC-0148	Profilnine SD (factor ix complex human)	J7194
ING-CC-0148	Rebinyn (glycopegylated)	J7203
ING-CC-0148	Rixubis (factor ix recombinant)	J7200
ING-CC-0149	Coagadex (factor x)	J7175
ING-CC-0149	Corifact (factor xiii concentrate (human))	J7180
ING-CC-0149	Feiba (anti-inhibitor coagulant complex)	J7198
ING-CC-0149	Fibryga (human fibrinogen)	J7177
ING-CC-0149	NovoSeven RT (factor viia recombinant)	J7189
ING-CC-0149	RiaSTAP (fibrinogen concentrate)	J7178
ING-CC-0149	Sevenfact (factor vlla recombinant)	J7212
ING-CC-0149	Tretten (coagulation factor xiii a-subunit (recombinant))	J7181

 

Step therapy updates

 

Effective for dates of service on and after February 1, 2023, 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 ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro, and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long‑acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.

 

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-0002*	Non-preferred	Fylnetra	J3590
ING-CC-0002*	Non-preferred	Rolvedon	C9399, J3490, J3590
ING-CC-0002*	Non-preferred	Stimufend	C9399, J3490, J3590
ING-CC-0002	Preferred	Neulasta	J2506
ING-CC-0002	Preferred	Neulasta OnPro	J2506
ING-CC-0002	Preferred	Udenyca	Q5111
ING-CC-0002	Non-preferred	Fulphila	Q5108
ING-CC-0002	Non-preferred	Nyvepria	Q5122
ING-CC-0002	Non-preferred	Ziextenzo	Q5120

*Oncology use is managed by AIM

 

This is a courtesy notice that there is a non-material change in the Clinical Criteria for Orencia ING-CC-0078.  The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s). 

 

Quantity limit updates

 

Effective for dates of service on and after February 1, 2023, 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-0017	Xiaflex (collagenase clostridium histolyticum)	J0775
ING-CC-0072	Cimerli (ranibizumab-cqrn)	J3590
ING-CC-0182	Feraheme (ferumoxytol)	Q0138
ING-CC-0182	Ferrlecit (ferric gluconate)	J2916
ING-CC-0182	Infed (iron dextran)	J1750
ING-CC-0182	Injectafer (ferric injection)	J1439
ING-CC-0182	Monoferric (ferric derisomaltose)	J1437
ING-CC-0182	Venofer (iron sucrose)	J1756
ING-CC-0220	Xenpozyme (olipudase alfa)	C9399, J3490, J3590
ING-CC-0221	Spevigo (spesolimab-sbzo)	C9399, J3490, J3590

 

* 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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