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

Prior authorization updates

 

Effective for dates of service on and after September 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 help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the Clinical Criteria information please click here.  

 

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 shown in italics in the table below.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0161	C9399 J3490 J3590 J9999	Sarclisa
*ING-CC-0058	J2354	Bynfezia

* 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 September 1, 2020, 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.

 

To access the step therapy drug list, please click here.

 

Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.

 

Clinical Criteria	Status	Drug(s)	HCPCS Code(s)
ING-CC-0003	Non-preferred	Panzyga	J1599
ING-CC-0003	Non-preferred	Xembify	J3490

 

* Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements

 

458-0620-PN-IN.OH.WI