Effective July 1, 2019, Anthem Federal Employee PPO members, (ID numbers beginning with an, ‘R’), aged 18 and older, and not Medicare Primary, will now need to have Prior Approval for the following medications:

 

List of medications by code

 

Code

Procedure Description

J0129

Abatacept injection (Orencia)

J0490

Belimumab injection (Benlysta)

J1459

Injection, immune globulin (Privigen)

J1555

Injection, immune globulin (Cuvitru)

J1556

Injection, immune globulin (Bivigam)

J1557

Injection, immune globulin (Gammaplex)

J1559

Injection, immune globulin (Hizentra)

J1561

Injection, immune globulin (Gamunex-c/Gammaked)

J1566

Injection, immune globulin (Carimune)

J1568

Injection, immune globulin (Octagam)

J1569

Injection, immune globulin (Gammagard liquid)

J1572

Injection, immune globulin (Flebogamma)

J1575

Injection, immune globulin/hyaluronidase  (HyQvia)

J1599

Injection, immune globulin (Panzyga)

J1602

Golimumab IV (Simponi Aria)

J1745

Infliximab not biosimilar (Remicade)

J2323

Natalizumab injection (Tysabri)

J3380

Vedolizumab Injection (Entyvio)

Q5103

Infliximab dyyb biosimilar (Inflectra)

Q5104

Infliximab abda biosimilar (Renflexis)

Q5109

infliximab-qbtx, biosimilar (Ixifi)

 

In addition to acquiring Prior Approval for the medication, the Outpatient Hospital Site of Care must also be approved.  The Prior Approval process will identify members who meet the appropriate Anthem site of care criteria and who can safely receive their medication in a location other than an outpatient hospital, including the home.

 

Effective January 1, 2020 failure to receive Prior Approval for these medications may result in non-coverage of the medication and facility services.

 

To acquire Prior Approval please contact the Anthem Federal Employee Program Utilization Management Department at (800-860-2156).

 



Featured In:
July 2019 Anthem Provider News - Wisconsin