Products & Programs PharmacyCommercialAugust 1, 2019

Clinical criteria and prior authorization updates for specialty pharmacy are available*

Below are clinical criteria and prior authorization updates were endorsed at the May 17, 2019 Clinical Criteria meeting. Click here to access the Clinical Criteria page on anthem.com

 

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. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.

 

Revised Clinical Criteria effective June 10, 2019

The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline

Clinical Criteria

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

CG-DRUG-106

ING-CC-0092

Adcetris (brentuximab) 

Adcetris

J9042

CG-DRUG-38

ING-CC-0094

Alimta (pemetrexed) 

Alimta

J9305

CG-DRUG-42

ING-CC-0096

Asparagine Specific Enzymes

Erwinaze, Asparaginase, Oncaspar

J9019, J9020, J9266

CG-DRUG-63

ING-CC-0104

Leucovorin and Levoleucovorin agents

Fusilev, Khapzory

J0641, C9043, J3490

CG-DRUG-66

ING-CC-0105

Vectibix (panitumumab) 

Vectibix

J9303

CG-DRUG-72

ING-CC-0110

Perjeta (pertuzumab) 

Perjeta

J9306

CG-DRUG-96

ING-CC-0115

Kadcyla (ado-trastuzumab)    

Kadcyla

J9354

CG-DRUG-98

ING-CC-0116

Bendamustine agents

Bendeka, Treanda, Belrapzo

J9034, J9033, C9042, J9999

DRUG.00046

ING-CC-0119

Yervoy (ipilimumab) 

Yervoy

J9228

DRUG.00053

ING-CC-0120

Kyprolis (carfilzomib) 

Kyprolis

J9047

DRUG.00063

ING-CC-0122

Arzerra (ofatumumab) 

Arzerra

J9302

DRUG.00067

ING-CC-0123

Cyramza (ramucirumab) 

Cyramza

J9308

DRUG.00071

ING-CC-0124

Keytruda (pembrolizumab) 

Keytruda

J9271

DRUG.00075

ING-CC-0125

Opdivo (nivolumab) 

Opdivo

J9299

DRUG.00107

ING-CC-0129

Bavencio (avelumab) 

Bavencio

J9023

 

Revised Clinical Criteria effective September 1, 2019

The following new clinical criteria were reviewed with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline

Clinical Criteria

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

CG-DRUG-100

ING-CC-0085

Actimmune (interferon gamma-1B) 

Actimmune

J9216

CG-DRUG-101

ING-CC-0090

Ixempra (ixabepilone) 

Ixempra

J9207

CG-DRUG-102

ING-CC-0091

Lartruvo (olaratumab) 

Lartruvo

J9285

CG-DRUG-49

ING-CC-0098

Doxorubicin Hydrochloride Liposome

Lipodox, Doxorubicin hydrochloride liposomal, Doxil

Q2049, Q2050

CG-DRUG-50

ING-CC-0099

Abraxane (paclitaxel protein-bound) 

Abraxane

J9264

CG-DRUG-51

ING-CC-0100

Istodax (romidepsin) 

Istodax

J9315

CG-DRUG-62

ING-CC-0103

Faslodex (fulvestrant) 

Faslodex

J9395

CG-DRUG-67

ING-CC-0106

Erbitux (cetuximab) 

Erbitux

J9055

CG-DRUG-68

ING-CC-0107

Bevacizumab agents (Avastin, Mvasi)

Avastin, Mvasi

J9035, Q5107

CG-DRUG-70

ING-CC-0108

Halaven (eribulin)   

Halaven

J9179

CG-DRUG-71

ING-CC-0109

Zaltrap (ziv-aflibercept) 

Zaltrap

J9400

CG-DRUG-75

ING-CC-0111

Nplate (romiplostim)

Nplate

J2796

CG-DRUG-77

ING-CC-0112

Xofigo (Radium Ra 223 Dichloride)

Xofigo

A9606, 79101

CG-DRUG-80

ING-CC-0114

Jevtana (cabazitaxel)    

Jevtana

J9043

CG-DRUG-99

ING-CC-0117

Empliciti (elotuzumab) 

Empliciti

J9176

CG-THER-RAD-03

ING-CC-0118

Radioimmunotherapy: Zevalin; azedra; Lutathera

Zevalin, Azedra, Lutathera

79403, A9543, 79101, A9699, C9408, A9513

DRUG.00062

ING-CC-0121

Gazyva (obinutuzumab) 

Gazyva

J9301

DRUG.00076

ING-CC-0126

Blincyto (blinatumomab) 

Blincyto

J9039

DRUG.00082

ING-CC-0127

Darzalex (daratumumab) 

Darzalex

J9145

DRUG.00088

ING-CC-0128

Tecentriq (atezolizumab) 

Tecentriq

J9022

DRUG.00109

ING-CC-0130

Imfinzi (durvalumab) 

Imfinzi

J9173

CG-DRUG-113

ING-CC-0131

Besponsa (inotuzumab ozogamicin) 

Besponsa

J9229

DRUG.00112

ING-CC-0132

Mylotarg (gemtuzumab ozogamicin) 

Mylotarg

J9203

DRUG.00118

ING-CC-0133

Aliqopa (copanlisib)

Aliqopa

J9057

MED.00106

ING-CC-0134

Provenge (Sipuleucel-T)

Provenge

Q2043

CG-MED-67

ING-CC-0135

Melanoma Vaccines

Imlygic

J9325, J3590

CG-DRUG-53

ING-CC-0136

Drug dosage, frequency, and route of administration

N/A

N/A

CG-DRUG-01

ING-CC-0141

Off-Label Drug and Approved Orphan Drug Use

N/A

N/A

 

Revised Clinical Criteria effective November 1, 2019

The following current and new clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

  • ING-CC-0048 Spinraza (nusinersen)
  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0113 Sylvant (siltuximab) [previously CG-DRUG-79]

 

New Clinical Criteria effective November 1, 2019

The following clinical criteria are new.

  • ING-CC-0137 Cablivi (caplacizumab-yhdp)
  • ING-CC-0138 Asparlas (calaspargase pegol-mknl)
  • ING-CC-0139 Evenity (romosozumab-aqqg)
  • ING-CC-0140 Zulresso (brexanolone)

 

Expanded specialty pharmacy prior authorization list

Effective for dates of service on and after November 1, 2019, the following non-oncology specialty pharmacy codes from current clinical criteria 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.

 

Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.

 

Clinical Criteria

HCPCS or CPT Code(s)

NDC Code(s)

Drug

ING-CC-0050

J3490

J3590

00074-2042-01 00074-2042-02

Skyrizi™

 

* Notice of 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.


PUBLICATIONS: August 2019 Anthem Provider News - Wisconsin