As part of our ongoing quality improvement efforts, Anthem Blue Cross and Blue Shield (Anthem) is updating our prior authorization processes for certain specialty medications. Effective August 1. 2021, we may request additional documentation for impacted medications to determine medical necessity.

 

Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.

 

Should you have any questions, please refer to the Clinical Criteria policy website for specific medication criteria details, including documentation requirements.

 

Impacted Policy

Impacted Medication(s)

ING-CC-0153: Adakveo (crizanlizumab)

Adakveo

ING-CC-0065: Agents for Hemophiilia A and von Willebrand Disease

Advate, Adynovate, Afstyla, Alphanate, Eloctate, Esperoct, Helixate FS, Hemlibra, Hemofil-M, Humate-P, Jivi, Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Wilate, Xyntha

ING-CC-0148: Agents for Hemophilia B

Alphanine SD, Alprolix, Bebulin, Benefix, Idelvion, Ixinity, Mononine, Profilnine SD, Rebinyn, Rixubis

ING-CC-0025: Aldurazyme (laronidase)

Aldurazyme

ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy

Aralast, Glassia, Prolastin-C, Zemaira

ING-CC-0028: Benlysta (belimumab)

Benlysta

ING-CC-0012: Brineura (cerliponase alfa)

Brineura

ING-CC-0137: Cablivi (caplacizumab-yhdp)

Cablivi

ING-CC-0041: Complement Inhibitors

Soliris, Ultomiris

ING-CC-0081: Crysvita (burosumab-twza)

Crysvita

ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)

Duopa

ING-CC-0029: Dupixent (dupilumab)

Dupixent

ING-CC-0069: Egrifta (tesamorelin)

Egrifta

ING-CC-0024: Elaprase (idursufase)

Elaprase

ING-CC-0173: Enspryng (satralizumab-mwge)

Enspryng

ING-CC-0051: Enzyme Replacement Therapy for Gaucher Disease

Cerezyme, Elelyso, Vpriv

ING-CC-0044: Exondys 51 (eteplirsen)

Exondys 51

ING-CC-0021: Fabrazyme (agalsidase beta)

Fabrazyme

ING-CC-0068: Growth hormone

Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive

ING-CC-0034: Hereditary Angioedema Agents

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

ING-CC-0188: Imcivree (setmelanotide)

Imcivree

ING-CC-0070: Jetrea (ocriplasmin)

Jetrea

ING-CC-0037: Kanuma (sebelipase alfa)

Kanuma

ING-CC-0057: Krystexxa (pegloticase)

Krystexxa

ING-CC-0018: Lumizyme (alglucosidase alfa)

Lumizyme

ING-CC-0013: Mepsevii (vestronidase alfa)

Mepsevii

ING-CC-0043: Monoclonal Antibodies to Interleukin-5

Cinqair, Fasenra, Nucala

ING-CC-0023: Naglazyme (galsulfase)

Naglazyme

ING-CC-0111: Nplate (romiplostim)

Nplate

ING-CC-0082: Onpattro (patisiran)

Onpattro

ING-CC-0077: Palynziq (pegvaliase-pqpz)

Palynziq

ING-CC-0049: Radicava (edaravone)

Radicava

ING-CC-0156: Reblozyl (luspatercept)

Reblozyl

ING-CC-0159: Scenesse (afamelanotide)

Scenesse

ING-CC-0149: Select Clotting Agents for Bleeding Disorders

Feiba, Novoseven

ING-CC-0079: Strensiq (asfotase alfa)

Strensiq

ING-CC-0008: Subcutaneous Hormonal Implants

Testopel

ING-CC-0084: Tegsedi (inotersen)

Tegsedi

ING-CC-0162: Tepezza (teprotumumab-trbw)

Tepezza

ING-CC-0170: Uplizna (inebilizumab)

Uplizna

ING-CC-0172: Viltepso (viltolarsen)

Viltepso

ING-CC-0022: Vimizim (elosulfase alfa)

Vimizim

ING-CC-0152: Vyondys 53 (golodirsen)

Vyondys 53

ING-CC-0017: Xiaflex (clostridial collagenase histolyticum) injection

Xiaflex

ING-CC-0033: Xolair (omalizumab)

Xolair

 

1204-0721-PN-CNT



Featured In:
July 2021 Anthem Provider News - Wisconsin