*Material Adverse Change (MAC)

 

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.

 

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

 

Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

Prior authorization updates

 

Effective for dates of service on and after July 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Access our Clinical Criteria to view the complete information for these step therapy updates.

 

Clinical Criteria

Drug

HCPCS or CPT Code(s)

ING-CC-0166*

Herzuma

Q5113

ING-CC-0166*

Ogivri

Q5114

ING-CC-0166*

Ontruzant

Q5112

ING-CC-0166*

Trazimera

Q5116

* Oncology use is managed by AIM.

 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

Step therapy updates

 

Effective for dates of service on and after July 1, 2022, 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.

 

Access our Clinical Criteria to view the complete information for these step therapy updates.

 

Clinical Criteria

Status

Drug

HCPCS or CPT Code(s)

ING-CC-0209

Non-preferred

Leqvio

J3490

ING-CC-0107*

Preferred

Avastin

J9035

Mvasi

Q5107

Non-preferred

Zirabev

Q5118

ING-CC-0166*

Preferred

Herceptin**

J9355

Kanjinti**

Q5117

Non-preferred

Herzuma

Q5113

Ogivri

Q5114

Ontruzant

Q5112

Trazimera

Q5116

*Oncology use is managed by AIM.

**Herceptin and Kanjinti are preferred trastuzumab agents that do not require prior authorization or step therapy.

 

1449-0422-PN-CNT

 



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April 2022 Anthem Provider News - Wisconsin