Specialty pharmacy updates effective July 1, 2022

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) 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 and 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_® (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, 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 July 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-0166*	Herzuma	Q5113
ING-CC-0166*	Ogivri	Q5114
ING-CC-0166*	Ontruzant	Q5112
ING-CC-0166*	Trazimera	Q5116

* 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 July 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. 

 

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-0209	Non-preferred	Leqvio	J3490
ING-CC-0107*	Preferred	Avastin	J9035
		Mvasi	Q5107
	Non-preferred	Zirabev	Q5118
ING-CC-0166*	Preferred	Herceptin**	J9355
		Kanjinti**	Q5117
	Non-preferred	Herzuma	Q5113
		Ogivri	Q5114
		Ontruzant	Q5112
		Trazimera	Q5116

*Oncology use is managed by AIM.

**Herceptin and Kanjinti are preferred trastuzumab agents that do not require prior authorization or step therapy.

 

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