Specialty pharmacy updates - February 2023

Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by Anthem Blue Cross and Blue Shield’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, a separate company. This would apply 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 submit a prior authorization for your patients’ continued use of these medications.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing for 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.

Reminder: Clinical Criteria name change

In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC‑XXXX; however, the content within the documents remains unchanged.

Prior authorization updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

* 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 May 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. 

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria CC-0107 currently has a step therapy preferring Avastin and the biosimilar Mvasi. This update is to notify that the new biosimilar Vegzelma will be added to existing step therapy as a non-preferred agent.

* Oncology use is managed by AIM.

Clinical Criteria CC-0072: This is a courtesy notice to notify that there is an expansion in the preferred products in the step therapy for Clinical Criteria CC-0072 Vascular Endothelial Growth Factor inhibitors. Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non-preferred to preferred product status.

Quantity limit updates

Effective for dates of service on and after May 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.