Updates for specialty pharmacy are available

Prior authorization updates

 

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of NDC 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 and 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-0164	J3490 J9999 C9399	Jelmyto
ING-CC-0165	J3490 J3590 J9999 C9399	Trodelvy
ING-CC-0061	J1950 J3490	Fensolvi

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

 

Site of care updates

 

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization site of care review process.

 

Access the site of care drug list.  

 

For Anthem Blue Cross and Blue Shield and 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-0153	J0791	Adakveo (crizanlizumab)
ING-CC-0139	J3111	Evenity (romosozumab)
ING-CC-0154	J0223	Givlaari (givosiran)
ING-CC-0156	J0896	Reblozyl (luspatercept)
ING-CC-0003	J1558	Xembify (immune globulin)
*ING-CC-0002	Q5120	Ziextenzo (pegfilgrastim-bmez)

 

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

 

REMINDER: Process for Medical Non-Oncology Specialty Drug reviews

 

Please follow these steps to submit medical non-oncology specialty drug reviews:

 

Action	Contact
Submit a new prior authorization request for a medical specialty drug review  Submit a re-authorization request for a medical specialty drug review previously performed by AIM	Call IngenioRx at 1-833-293-0659 or Fax IngenioRx at 1-888-223-0550
Inquire about an existing request (initially submitted to AIM or IngenioRx), peer-to-peer review, or reconsideration	Call IngenioRx

 

Please note:

 

• AIM continues to be responsible for performing medical oncology drug reviews for existing commercial medical benefit for our employer group business.

• Clinical criteria for medical non-oncology specialty drugs continue to reside on the clinical criteria Web page.

• Post-service clinical coverage reviews and grievance and appeals process and teams have not changed.

 637-0920-PN-VA