Anthem Blue Cross and Blue Shield | CommercialSeptember 16, 2024
Specialty pharmacy updates — October 2024
The 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.
Note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request a prior authorization review for your patients’ continued use of these medications.
The inclusion of a National Drug Code (NDC) code on your claim will help expedite the claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on or after January 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 at https://tinyurl.com/4dv6rxe4 to view the complete information for these prior authorization updates.
Clinical Criteria | Drug | HCPCS or CPT® code(s) |
CC-0265 | Kisunla (donanemab) | J0175 |
CC-0041 | Piasky (crovalimab-akkz) | J3590 |
Step therapy updates
Effective for dates of service on or after January 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 at https://tinyurl.com/4dv6rxe4 to view the complete information for these step therapy updates.
Clinical Criteria | Status | Drug | HCPCS or CPT code(s) |
CC-0078 | Non-Preferred | Orencia | J0129 |
CC-0078 | Preferred | Avsola | Q5121 |
CC-0078 | Preferred | Remicade | J1745 |
CC-0078 | Preferred | Unbranded Infliximab | J1745 |
CC-0078 | Preferred | Simponi Aria | J1602 |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on or after January 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 at https://tinyurl.com/4dv6rxe4 to view the complete information for these quantity limit updates.
Clinical Criteria | Drug | HCPCS or CPT code(s) |
CC-0265 | Kisunla (donanemab) | J0175 |
CC-0041 | Piasky (crovalimab-akkz) | J3590 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CM-067804-24-CPN67634
PUBLICATIONS: October 2024 Provider Newsletter
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