Specialty pharmacy updates — November 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.

For Anthem Blue Cross and Blue Shield and its 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), and POS AdvantageOne, Act Wise (CDH plans).

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) on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

The health plan 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 or after February 1, 2025, 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.

Step therapy updates

Effective for dates of service on or after February 1, 2025, 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 current Orencia step therapy preferred product list under the medical benefit is being modified to include only those that are considered medical benefit drugs.

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

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 February 1, 2025, 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.

Quantity limit updates

Effective for dates of service on or after February 1, 2025, 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.