Specialty pharmacy updates effective January 1, 2023

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 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 preservice clinical review by AIM. This would apply to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Inclusion of the National Drug Code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified 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 National Drug Code is not reported on the same claim.

 

Step therapy updates

 

Effective for dates of service on and after January 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. 

Please note that infliximab agents are subject to step therapy today, and this is to notify of the changes in the preferred and nonpreferred products. Inflectra will become non-preferred and Avsola will become preferred as of January 1, 2023.

 

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-0062	Preferred	Avsola	Q5121
ING-CC-0062	Preferred	Infliximab Unbranded	J1745
ING-CC-0062	Preferred	Remicade	J1745
ING-CC-0062	Non-preferred	Inflectra	Q5103
ING-CC-0062	Non-preferred	Renflexis	Q5104

 

 

* 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.

 

VABCBS-CM-008062-22-CPN6800