Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new clinical criteria or current clinical guideline will be included in our prior authorization review process.

 

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

 

Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.

 

To access the clinical criteria information, please visit our Clinical Criteria website.

Clinical Criteria/Guideline

HCPCS or CPT Code

NDC Code

Drug

CG-DRUG-63

J3490

68152-0112-01

68152-0114-01

Khapzory™

ING-CC-0002

Q5110

00069-0291-10

00069-0291-01

00069-0292-01

00069-0292-10

Nivestym™

ING-CC-0002

J3490

68152-0112-01

68152-0114-01

Udenyca™

ING-CC-0003

J1599

68982-0820-01

68982-0820-02

68982-0820-03

68982-0820-04

68982-0820-05

68982-0820-06

68982-0820-81

68982-0820-82

68982-0820-83

68982-0820-84

68982-0820-85

68982-0820-86

Panzyga®

ING-CC-0034

J3590

47783-0644-01

Takhzyro®

ING-CC-0062

J3590

61314-0871-02

61314-0871-06

61314-0876-02

Hyrimoz™

ING-CC-0062

Q5109

00069-0811-01

Ixifi™

ING-CC-0065

J7192

00026-3942-25

00026-3944-25

00026-3946-25

00026-3948-25

00026-4942-01

00026-4944-01

00026-4946-01

00026-4948-01

Jivi®

ING-CC-0074

J8655

69639-0102-01

Akynzeo®

ING-CC-0077

C9399

J3590

68135-0058-90

68135-0673-40

68135-0673-45

68135-0756-20

Palynziq™

ING-CC-0081

J0584

69794-0102-01

69794-0203-01

69794-0304-01

Crysvita®

ING-CC-0082

C9399

J3490

71336-1000-01

Onpattro™



Featured In:
February 2019 Anthem Wisconsin Provider Newsletter