Specialty pharmacy updates - August 2023

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

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 Carelon Medical Benefits Management, Inc.* 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.

Anthem 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 November 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 site of prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

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

Step therapy updates

We are excited to announce the publication of a Medical Step Therapy Drug List. This list serves as an easy to access reference of the preferred and non-preferred products for each of the specialty pharmacy step therapy categories. The link to the pdf document is on the Clinical Criteria homepage.

Access our Clinical Criteria to view the Medical Step Therapy Drug List.

Quantity limit updates

Effective for dates of service on and after November 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.