Updates for specialty pharmacy are available

Prior authorization updates

Effective for dates of service on and after September 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 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 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-0191	J3490, J9999, C9399	Pepaxto
**ING-CC-0192	J3490, C9399	Cosela
*ING-CC-0193	J3490, C9399	Evkeeza
*ING-CC-0194	J3490	Cabenuva
*ING-CC-0167	J9999, J3590, C9399	Riabni

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

** Oncology use is managed by AIM.

 

Step therapy updates

Effective for dates of service on and after July 1, 2021, 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. 

Inflectra is changing to preferred status effective July 1, 2021

Access the Clinical Criteria information.

For Anthem Blue Cross and Blue Shield along with 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-0062	Preferred	Inflectra	Q5103
ING-CC-0062	Preferred	Remicade	J1745
ING-CC-0062	Non-preferred	Avsola	Q5121
ING-CC-0062	Non-preferred	Renflexis	Q5104

 

1184-0621-PN-VA