Specialty pharmacy updates – June 2023

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

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Medical Specialty Drug Review team for Anthem. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.,* a separate company. 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, a separate company. This would apply to members with Preferred Provider Organization (PPO), HealthKeepers, Inc. (HMO), POS AdvantageOne, 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.

By including the National Drug Code (NDC) on your claim may help expedite processing of drugs billed with a not otherwise classified (NOC) code. 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 September 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.

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 September 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.