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-004937-22-CPN4902 September 2022

  September 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.

  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 December 1, 2022, the following specialty pharmacy codes from new clinical criteria documents will be included in our prior authorization review process.

  Clinical Criteria is available at www.anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html

  Clinical Criteria Drug HCPCS or CPT® code(s) ING-CC-0217 Amvuttra™ (vutrisiran) J3490, J3590 ING-CC-0218 Xipere® (triamcinolone acetonide injectable suspension) J3299

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

  Quantity limit updates Effective for dates of service on and after December 1, 2022, the following specialty pharmacy codes from new clinical criteria documents will be included in our quantity limit review process.

  Clinical Criteria Drug HCPCS or CPT® code(s) ING-CC-0217 Amvuttra (vutrisiran) J3490, J3590 ING-CC-0218 Xipere (triamcinolone acetonide injectable suspension) J3299

  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