CommercialNovember 18, 2024
Material adverse change
Specialty pharmacy updates — December 2024
Specialty pharmacy updates for 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 Carelon Medical Benefits Management, Inc., a separate company.
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.
Prior authorization updates
Effective for dates of service on or after March 1, 2025, 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 prior authorization updates.
Clinical Criteria | Drug | HCPCS or CPT® code(s) |
CC-0267 | Ebglyss (lebrikizumab-lbkz) | C9399, J3590 |
CC-0072 | Eylea (aflibercept) biosimilars: Ahzantive (aflibercept-mrbb) | C9399, J3590 |
CC-0268* | Lymphir (denileukin diftitox-cxdl) | C9399, J9999 |
CC-0269 | Nemluvio (nemolizumab-ilto) | C9399, J3590 |
CC-0270* | Niktimvo (axatilmab-csfr) | C9399, J3590 |
CC-0011 | Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) | J3590 |
CC-0271 | Tecelra (afamitresgene autoleucel) | C9399, J9999 |
* Oncology use is managed by Carelon Medical Benefits Management.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on or after March 1, 2025, 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) |
CC-0011 | Non-preferred | Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) | J3590 |
Quantity limit updates
Effective for dates of service on or after March 1, 2025, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
Clinical Criteria | Drug | HCPCS or CPT code(s) |
CC-0267 | Ebglyss (lebrikizumab-lbkz) | C9399, J3590 |
CC-0072 | Eylea (aflibercept) biosimilars: Ahzantive (aflibercept-mrbb) | C9399, J3590 |
CC-0269 | Nemluvio (nemolizumab-ilto) | C9399, J3590 |
CC-0011 | Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) | J3590 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWI), Compcare Health Services Insurance Corporation (Compcare), and Wisconsin Collaborative Insurance Company (WCIC). BCBSWI underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CM-072458-24-CPN72383
To view this article online:
Visit https://providernews.anthem.com/wisconsin/articles/specialty-pharmacy-updates-december-2024-23027
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