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

Prior authorization list expansion for specialty pharmacy

 

Effective for dates of service on and after December 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.

 

Clinical Criteria	HCPCS or CPT Code(s)	NDC Code(s)	Drug
ING-CC-0031	J3490	71879-0136-01	Yutiq™
ING-CC-0003	J3490 J3590 C9399	68982-0810-01 68982-0810-02 68982-0810-03 68982-0810-04 68982-0810-05 68982-0810-06	Cutaquig®
ING-CC-0003	J1599	69800-0250-01	Asceniv™

 

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 updates for specialty pharmacy

 

Clinical criteria ING-CC-0061 addresses the use of gonadotropin releasing hormone analogs for the treatment of non-oncologic indications.

 

Effective for dates of service on and after December 1, 2019, the use of Zoladex for the treatment of endometriosis will be limited to six months.

 

Click here to access the Clinical Criteria page on anthem.com.

 

^{* 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.}