Specialty pharmacy updates – May 2023

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

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Anthem Medical Specialty Drug Review Team. 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.

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.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code. The health plan requires claims for injection services performed in the office setting include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding 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 August 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, Inc.

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

Site of care updates

Effective for dates of service on and after August 1, 2023, 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.

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be removed from our site of care review process.

Quantity limit updates

Effective for dates of service on and after August 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.