CurrentAnthemPolicy N/A

Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

Notifies that, effective August 1, 2023, Anthem Blue Cross and Blue Shield is adding specific Medicare Part B specialty drugs (reported via J-codes and miscellaneous codes J3490/J3590) to its precertification review process for specialty pharmacy. Applies to Anthem commercial and Medicare plans subject to federal/state/CMS rules.

Policy Summary

PayerAnthem

PolicyAnthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

Policy CodePolicy N/A

Change TypeAddition to precertification list

Effective DateAug 1, 2023

Next Review Date

Key ActionObtain precertification from Anthem for Briumvi (ublituximab) and Leqembi (lecanemab) administered under Medicare Part B (including claims billed to J3490/J3590) for dates of service on and after 2023-08-01; failure to precertify may result in claim denials.

SourceLink

POLICY UPDATE CHANGES

Briumvi (ublituximab) added to the specialty pharmacy precertification review list for Medicare Part B drugs effective 2023-08-01.

Leqembi (lecanemab) added to the specialty pharmacy precertification review list for Medicare Part B drugs effective 2023-08-01.

Precertification process applies to claims billed with J3490 and J3590 where appropriate for the listed Medicare Part B specialty drugs.

2Drugs added to precertification list

What is changing

Anthem is expanding its specialty pharmacy precertification requirements to include certain Medicare Part B drugs. Effective 2023-08-01, Briumvi (ublituximab) and Leqembi (lecanemab) reported via J3490, J3590, or the appropriate Medicare Part B J-code will be included in the precertification review process. Providers must obtain precertification for these affected drugs for dates of service on and after the effective date or risk claim denials.

Precertification updates & provider requirements

Precertification requirement for listed Medicare Part B specialty drugs

Effective for dates of service on and after August 1, 2023, the following drugs will be included in the precertification review process:

Precertification-targeted drugs

Briumvi (ublituximab) reported via J3490, J3590, or the appropriate Medicare Part B drug J-code will be subject to precertification review
Leqembi (lecanemab) reported via J3490, J3590, or the appropriate Medicare Part B drug J-code will be subject to precertification review

Precedence and applicability

Federal/state law and CMS guidelines supersede these precertification rules

Governing law and guidance: Federal and state law, state contract language, and CMS guidelines take precedence when determining coverage
Denial risk: Noncompliance with new precertification requirements may result in denied claims

Prior Authorization

Precertification required for listed drugs

Providers must obtain precertification from Anthem for Briumvi (ublituximab) and Leqembi (lecanemab) administered under Medicare Part B for dates of service on or after 2023-08-01. This requirement covers claims billed using J3490 and J3590 where those miscellaneous codes are used.

Affected codes: J3490, J3590, appropriate Medicare Part B drug J-codes when available
Effective date: 2023-08-01

Denial Risk

Claims denial risk for noncompliance

Claims for the listed specialty Medicare Part B drugs may be denied if precertification requirements are not met. Applicable federal, state, and CMS rules and contract language apply and may affect coverage and denial determinations.

Note: This includes claims billed to J3490/J3590 when those codes are used for these drugs.

Affected codes

Precertification-targeted codes (listed examples)mixedCovered

J3490	Unclassified drugs (used here to capture certain Medicare Part B specialty drugs pending specific J-code)
J3590	Unclassified biologics (used here to capture certain Medicare Part B specialty drugs pending specific J-code)
Medicare Part B drugs	Placeholder indicating the applicable specific J-codes for the listed specialty drugs (e.g., specific J-codes for ublituximab and lecanemab when available)

Billing Rule

Use specific J-codes when available; J3490/J3590 claims subject to precertification

Claims billed with J3490 and J3590 for the listed Medicare Part B specialty drugs are subject to the precertification process; when a specific J‑code exists for a drug, use that specific code instead of a miscellaneous J‑code. Federal and state law, state contract language, and CMS guidelines take precedence in determining coverage.

Use the specific Medicare Part B J-code for a drug when available rather than J3490/J3590
Federal/state/CMS guidelines take precedence

Document changes

2023-08-01addition