Specialty pharmacy updates — January 2024

Specialty pharmacy updates for 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 Carelon Medical Benefits Management, Inc., a separate company.

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 the National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Correction: In the August 2023 edition of Provider News, we announced prior authorizations for Zynyz would be effective November 2023. In the September 2023 edition of Provider News, we announced prior authorizations for Epkinly would be effective December 2023.

Please be advised that the prior authorization effective date for Epkinly and Zynyz is January 1, 2024.

* Oncology use is managed by Carelon Medical Benefits Management.

Effective for dates of service on and after April 1, 2024, 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.

* 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

Effective for dates of service on and after April 1, 2024, 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.

The preferred product in the Tyruko step therapy is generic dimethyl fumarate.

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

Courtesy notice

Effective on or after October 30, 2023, step therapy criteria for vascular endothelial growth factor (VEGF) inhibitors found in Clinical Criteria document CC-0072 expands the preferred product list to include Eylea HD. Please refer to Clinical Criteria document for details.

Quantity limit updates

Effective for dates of service on and after April 1, 2024, 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.

Site of care updates

Effective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.

Access our Clinical Criteria to view the complete information for these site of care updates.