Specialty pharmacy updates for March 2023

For Anthem Blue Cross and Blue Shield 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 Carelon Medical Benefits Management, Inc., 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 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 June 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 prior authorization updates.

 

Clinical Criteria	Drug	HCPCS or CPT® code(s)
CC-0227	Briumvi (ublituximab)	J3490, J3590
CC-0228	Leqembi (lecanemab)	J3490, J3590
CC-0229	Sunlenca (lenacapavir)	J3490, C9399

 

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 January 17, 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	Status	Drug	HCPCS or CPT code(s)
CC-0227	Non-preferred	Briumvi (ublituximab)	J3490, J3590

 

Quantity limit updates

Effective for dates of service on and after June 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.

 

Clinical Criteria	Drug	HCPCS or CPT code(s)
CC-0227	Briumvi (ublituximab)	J3490, J3590
CC-0229	Sunlenca (lenacapavir)	J3490, C9399

 

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

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