Updates for specialty pharmacy are available

Prior authorization updates

 

Effective for dates of service on and after August 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 NDC 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-0186	J3490, J3590, J9999	Margenza
*ING-CC-0187	J3490, J3590, J9999	Breyanzi
*ING-CC-0188	J3490, J3590	Imcivree
*ING-CC-0189	J3490, J3590, C9399	Amondys 45
*ING-CC-0190	J3490, J3590, C9399	Nulibry
**ING-CC-0094	J9304	Pemfexy
**ING-CC-0075	J3590, J9999, C9399	Riabni

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

** Oncology use is managed by AIM.

 

Prior authorization update – change in clinical criteria

 

Coding Update: Effective August 18, 2020, these unclassified codes, J3490 and J3590, were removed from clinical criteria ING-CC-0072.

 

Quantity limit updates

 

Effective for dates of service on and after August 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit 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 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 the NDC 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).

 

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-0189	J3490. J3590, C9399	Amondys 45
*ING-CC-0190	J3490, J3590, C9399	Nulibry

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

** Oncology use is managed by AIM.

 

1138-0521-PN-VA