Prior Authorization Specialty Pharmacy Updates Form

P.O. Box 4330 Woodland Hills, CA 91365

• AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross.

  Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
  CABC-CM-010233-22-CPN9363
  October 2022

  November 1, 2022

  Re: Specialty Pharmacy Updates

  Dear Provider:

  Specialty pharmacy updates for Anthem Blue Cross (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 AIM Specialty Health® (AIM), a separate company.

  Important to 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. Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

  Prior authorization updates

  Effective for dates of service on and after February 1, 2023, 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 at https://www.anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these prior authorization updates.

  Clinical Criteria Drug HCPCS or CPT Code(s) ING-CC-0002 Fylnetra (pegfilgrastim-pbbk) J3590 ING-CC-0002 Rolvedon (eflapegrastim-xnst) C9399, J3490, J3590 ING-CC-0002* Stimufend (pegfilgrastim-fpgk) C9399, J3490, J3590 ING-CC-0072 Cimerli (ranibizumab-cqrn) J3590 ING-CC-0220 Xenpozyme (olipudase alfa) C9399, J3490, J3590 ING-CC-0221 Spevigo (spesolimab-sbzo) C9399, J3490, J3590

• Oncology use is managed by AIM.

  Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

  Site of care updates

  Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current clinical criteria documents will be included in our site of care review process. Clinical Criteria Drug HCPCS or CPT Code(s) ING-CC-0065 Advate (factor viii (antihemophilic factor, recombinant)) J7192
  ING-CC-0065 Adynovate (factor vii) J7207 ING-CC-0065 Afstyla (antihemophilic factor (recombinant) single chain)) J7210 ING-CC-0065 Alphanate (antihemophilic factor viii) J7186 ING-CC-0065 Eloctate (recombinant antihemophilic factor) J7205

ING-CC-0065 Esperoct (factor viii recombinant, glycopegylated) J7204 ING-CC-0065 factor viii, anti-hemophilic factor (porcine) J7191
ING-CC-0065 Hemlibra (emicizumab-kxwh) J7170 ING-CC-0065 Hemofil M ((factor viii) human plasma-derived) J7190 ING-CC-0065 Humate-P (antihemophilic factor viii) J7187 ING-CC-0065 Jivi (factor viii, recombinant, pegylated-aucl) J7208 ING-CC-0065 Koate DVI ((factor viii) human plasma-derived) J7190 ING-CC-0065 Kogenate-FS (factor viii (antihemophilic factor, recombinant)) J7192
ING-CC-0065 Kovaltry (factor viii (antihemophilic factor, recombinant)) J7211 ING-CC-0065 Novoeight (factor viii (antihemophilic factor, recombinant)) J7182 ING-CC-0065 Nuwiq (factor viii (antihemophilic factor, recombinant)) J7209 ING-CC-0065 Obizur (antihemophilic factor viii (recombinant)) J7188 ING-CC-0065 Recombinate (factor viii (antihemophilic factor, recombinant)) J7192
ING-CC-0065 Vonvendi (von willebrand factor) J7179 ING-CC-0065 Wilate (antihemophilic factor viii) J7183 ING-CC-0065 Xyntha (factor viii (antihemophilic factor, recombinant)) J7185 ING-CC-0065 Xyntha Solofus (factor viii (antihemophilic factor, recombinant)) J7185 ING-CC-0148 AlphaNine SD (coagulation factor ix (human)) J7193 ING-CC-0148 Alprolix (recombinant coagulation factor ix) J7201 ING-CC-0148 Benefix (factor ix recombinant) J7195 ING-CC-0148 Idelvion (factor ix) J7202 ING-CC-0148 Ixinity (factor ix) J7195 ING-CC-0148 Mononine (coagulation factor ix (human)) J7193 ING-CC-0148 Profilnine SD (factor ix complex human) J7194 ING-CC-0148 Rebinyn (glycopegylated) J7203 ING-CC-0148 Rixubis (factor ix recombinant) J7200 ING-CC-0149 Coagadex (factor x) J7175 ING-CC-0149 Corifact (factor xiii concentrate (human)) J7180 ING-CC-0149 Feiba (anti-inhibitor coagulant complex) J7198 ING-CC-0149 Fibryga (human fibrinogen) J7177 ING-CC-0149 NovoSeven RT (factor viia recombinant) J7189 ING-CC-0149 RiaSTAP (fibrinogen concentrate) J7178 ING-CC-0149 Sevenfact (factor vlla recombinant) J7212 ING-CC-0149 Tretten (coagulation factor xiii a-subunit (recombinant)) J7181

Step therapy updates

Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

Clinical criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long-acting colony stimulating factor Rolvedon will be added to existing step therapy as non-preferred agents.

Clinical Criteria

Status Drug HCPCS or CPT Code(s) ING-CC-0002 Non-preferred Fylnetra J3590 ING-CC-0002 Non-preferred Rolvedon C9399, J3490, J3590 ING-CC-0002* Non-preferred Stimufend C9399, J3490, J3590 ING-CC-0002 Preferred Neulasta J2506

ING-CC-0002 Preferred Neulasta OnPro J2506 ING-CC-0002 Preferred Udenyca Q5111 ING-CC-0002 Non-preferred Fulphila Q5108 ING-CC-0002 Non-preferred Nyvepria Q5122 ING-CC-0002 Non-preferred Ziextenzo Q5120 *Oncology use is managed by AIM

This is a courtesy notice that there is a non-material change in the clinical criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).

Quantity limit updates

Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

Clinical Criteria Drug HCPCS or CPT Code(s) ING-CC-0017 Xiaflex (collagenase clostridium histolyticum) J0775 ING-CC-0072 Cimerli (ranibizumab-cqrn) J3590 ING-CC-0182 Feraheme (ferumoxytol) Q0138 ING-CC-0182 Ferrlecit (ferric gluconate) J2916 ING-CC-0182 Infed (iron dextran) J1750 ING-CC-0182 Injectafer (ferric injection) J1439 ING-CC-0182 Monoferric (ferric derisomaltose) J1437 ING-CC-0182 Venofer (iron sucrose) J1756 ING-CC-0220 Xenpozyme (olipudase alfa) C9399, J3490, J3590 ING-CC-0221 Spevigo (spesolimab-sbzo) C9399, J3490, J3590

We thank you for your continued efforts on behalf of our members and your partnership toward improved access to quality health care for Californians.
Sincerely,

John Yao, MD, MPH, MBA, MPP, FACP
Chief Medical Officer