Updates for specialty pharmacy are available

Prior authorization updates

 

Effective for dates of service on and after June 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

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 the Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.

 

Please note, inclusion of National Drug Code code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

Access the Clinical Criteria information.

 

For Anthem Blue Cross and Blue Shield along with our 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 AIM Specialty Health_® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0185	J3490 C9399	Oxlumo
**ING-CC-0184	J3490 J3590 J9999	Danyelza

*Non-oncology use is managed by the medical specialty drug review team. Oncology use is managed by AIM.

** Oncology use is managed by AIM.

 

Prior authorization update – change in effective date

 

Please note the change in date for the implementation of prior authorization for injectable iron deficiency anemia products.

 

The effective date has been changed to dates of service on and after May 1, 2021, for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our prior authorization review process. The previous effective date was March 1, 2021.

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, 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.

 

Please note, inclusion of National Drug Code code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified code.

Access the Clinical Criteria information.

For Anthem Blue Cross and Blue Shield and 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 AIM Specialty Health_® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0182	J1756	Venofer
*ING-CC-0182	J2916	Ferrlecit
*ING-CC-0182	J1750	Infed
*ING-CC-0182	J1439	Injectafer
*ING-CC-0182	Q0138	Feraheme
*ING-CC-0182	J1437	Monoferric

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

Step therapy update – change in effective date

 

Please note the change in the effective date of step therapy for injectable iron deficiency anemia products.

 

The effective date has been changed to dates of service on and after May 1, 2021, for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our existing specialty pharmacy medical step therapy review process. The previous effective date was March 1, 2021.

 

Access the step therapy drug list.

For Anthem Blue Cross and Blue Shield and 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 AIM Specialty Health_® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

Clinical Criteria	Status	Drug(s)	HCPCS Codes
*ING-CC-0182	Preferred	Venofer	J1756
*ING-CC-0182	Preferred	Ferrlecit	J2916
*ING-CC-0182	Preferred	Infed	J1750
*ING-CC-0182	Non-preferred	Injectafer	J1439
*ING-CC-0182	Non-preferred	Feraheme	Q0138
*ING-CC-0182	Non-preferred	Monoferric	J1437

 

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

Prior authorization update – change in code list

 

In a recent notification, we shared that effective April 1, 2021, the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization process at this time.

 

Access the Clinical Criteria information.

 

For Anthem Blue Cross and Blue Shield and 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 AIM Specialty Health_® (AIM), a separate company.

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0095	J9041	Velcade (Bortezomib)
**ING-CC-0095	J9041	Velcade (Bortezomib)
*ING-CC-0095	J9044	Bortezomib
**ING-CC-0095	J9044	Bortezomib
*ING-CC-0093	J9171	Docetaxel
**ING-CC-0093	J9171	Docetaxel

 

*Non-oncology use is managed by Anthem’s medical specialty drug review team.

**Oncology use is managed by AIM.

 

Prior authorization update – Medical specialty pharmacy update

 

In an effort to simplify care and support our providers, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions, effective May 1, 2021.

 

Drug	Code	Code description
*Avastin	C9257 J9035	intravitreal bevacizumab
*Mvasi	Q5107	bevacizumab-awwb
*Zirabev	Q5118	bevacizumab-bvzr

*Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

1007-0321-PN-VA