Anthem prior authorization updates for specialty pharmacy are available - April 2020*

Prior authorization updates

Effective for dates of service on and after July 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents 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.

 

To access the clinical criteria document information please visit https://www11.anthem.com/pharmacyinformation/clinicalcriteria.html.

 

Anthem Blue Cross and Blue Shield (Anthem)’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.

 

Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health_® (AIM), a separate company and are in italics.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0003	C9399 J3490 J3590	Xembify
ING-CC-0062	J3590	Eticovo
ING-CC-0062	J3490	Hadlima
ING-CC-0072	J0179	Bevou
ING-CC-0152	J3490	Vyondys 53
ING-CC-0153	C9399 J3490 J3590	Adakveo
ING-CC-0154	C9399 J3490 J3590	Givlaari

* Non-oncology use is managed by Anthem’s medical specialty drug review team. 

  Oncology use is managed by AIM.

 

Step therapy updates

 

Effective for dates of service on and after July 1, 2020, the following specialty pharmacy codes from new or current clinical criteria will be included in our existing specialty pharmacy medical step therapy review process.

 

Orencia will be the non-preferred agent for rheumatoid arthritis, polyarticular juvenile idiopathic arthritis and psoriatic arthritis. The table below will assist you in identifying the applicable preferred agents and clinical criteria.

 

To access the clinical criteria document information please visit https://www11.anthem.com/pharmacyinformation/clinicalcriteria.html.

 

Rheumatoid Arthritis (RA)

 

Clinical Criteria	HCPCS or CPT Code	Preferred Agents	Clinical Criteria	HCPCS or CPT Code	Non-Preferred Agent
ING-CC-0062	J1438	Enbrel	ING-CC-0078	J0129	Orencia
ING-CC-0062	J0135	Humira
ING-CC-0062	J3590	Simponi
ING-CC-0062	J1602	Simponi Aria
ING-CC-0062	J1745	Remicade

 

Polyarticular Juvenile Idiopathic Arthritis (PJIA)

 

Clinical Criteria	HCPCS or CPT Code	Preferred Agents	Clinical Criteria	HCPCS or CPT Code	Non-Preferred Agent
ING-CC-0062	J1438	Enbrel	ING-CC-0078	J0129	Orencia
ING-CC-0062	J0135	Humira

 

Psoriatic Arthritis (PsA)

 

Clinical Criteria	HCPCS or CPT Code	Preferred Agents	Clinical Criteria	HCPCS or CPT Code	Non-Preferred Agent
ING-CC-0042	C9399 J3490 J3590	Cosentyx	ING-CC-0078	J0129	Orencia
ING-CC-0062	J1438	Enbrel
ING-CC-0062	J0135	Humira
ING-CC-0062	J3590	Simponi
ING-CC-0062	J1602	Simponi Aria
ING-CC-0062	J1745	Remicade
ING-CC-0063	J3357	Stelara