Specialty pharmacy updates effective March 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 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 Specialty Health.

 

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

 

Please note that 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 NDC, for the injected substance. This requirement is consistent with Centers for Medicare & Medicaid Services 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 March 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	HCPCS or CPT Code(s)	Drug
*ING-CC-0018	J3490 J3590 C9399	Nexviazyme (avalglucosidase alfa-ngpt)
*ING-CC-0034	J1744	Sajazir (icatibant)

 

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

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 March 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	HCPCS or CPT Code(s)	Drug
*ING-CC-0018	J3490 J3590 C9399	Nexviazyme (avalglucosidase alfa-ngpt)
*ING-CC-0034	J1744	Sajazir (icatibant)

 

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

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