CurrentAnthemPolicy N/A

Specialty pharmacy precertification list expansion — Medicare Part B drugs

Defines addition of specific Medicare Part B specialty drugs to Anthem's specialty pharmacy precertification review process for dates of service on/after July 1, 2022; affects providers submitting claims for Medicare Part B drugs under Anthem plans.

Policy Summary

PayerAnthem

PolicySpecialty pharmacy precertification list expansion — Medicare Part B drugs

Policy CodePolicy N/A

Change TypeAdded drugs to precertification list

Effective DateJuly 1, 2022

Next Review DateN/A

Key ActionObtain precertification for the listed Medicare Part B specialty drugs using the associated HCPCS codes before billing.

SourceLink

POLICY UPDATE CHANGES

The listed Medicare Part B specialty drugs (Fyarro, Besremi, Vyvgart, Adbry, Legvio) were added to Anthem's specialty pharmacy precertification review process effective July 1, 2022.

5Medicare Part B specialty drugs added to precertification list

Jul 1, 2022Effective date for precertification requirement

J3490, J3590, C9399Billing HCPCS codes referenced for listed drugs

Medicare Part BLine of benefits affected

Coverage / Policy Criteria

Precertification Inclusion

Anthem will include the following Medicare Part B specialty drugs in its precertification review process for dates of service on/after July 1, 2022.

Listed drugs included: Fyarro, Besremi, Vyvgart, Adbry, Legvio are subject to precertification review under Anthem's specialty pharmacy program starting 7/1/2022.

No clinical eligibility criteria provided in the document.

Federal and state law, state contract language, and CMS guidelines, including definitions and specific contract provisions or exclusions, take precedence and must be applied first when determining coverage for Medicare Part B specialty drugs included in this precertification process. Effective for dates of service on or after July 1, 2022, Anthem has added the listed Medicare Part B specialty drugs to its specialty pharmacy precertification review. Providers should follow applicable federal/state requirements and contract terms in addition to Anthem’s precertification rules.

Billing Codes

Referenced HCPCS Codes for listed drugsHCPCS

J3490	Unclassified drugs (used here referencing multiple listed Medicare Part B specialty drugs)
J3590	Unclassified biologics (used here referencing multiple listed Medicare Part B specialty drugs)
C9399	Unclassified drugs or biologicals (used here referencing Vyvgart)

Policy Summary

PayerAnthem

PolicySpecialty pharmacy precertification list expansion — Medicare Part B drugs

Policy CodePolicy N/A

Change TypeAdded drugs to precertification list

Effective DateJuly 1, 2022

Next Review DateN/A

Key ActionObtain precertification for the listed Medicare Part B specialty drugs using the associated HCPCS codes before billing.

SourceLink

On This Page

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Provider Responsibilities & Actions

Prior Authorization

Prior Authorization Required

Precertification (prior authorization) is required for the listed Medicare Part B specialty drugs beginning on the effective date.

Prior authorization required using the associated HCPCS/administration billing codes starting 07/01/2022
Affected HCPCS examples from source: J3490, J3590, C9399 (see documentation block for submission guidance)

Note

Providers: ensure prior authorization is obtained before administration and keep this callout in mind for any related member care coordination.

Documentation Required

Documentation for Precertification

Submit the precertification request to Anthem Specialty Pharmacy/Precertification per Anthem processes. Required documentation includes: clinical indication, diagnosis, supporting clinical notes, prior treatment history, and HCPCS/NDC details. Include the specific HCPCS code(s) reported for the drug (e.g., J3490, J3590, C9399) and any drug-specific descriptors to allow correct routing and review. Follow Anthem’s specialty pharmacy precertification submission portal or fax procedures and retain copies of submitted supporting records.

Required documentation: clinical rationale, diagnosis, prior therapies, relevant labs/imaging, and HCPCS code(s) billed
Use Anthem specialty pharmacy precertification submission processes (portal/fax) and include HCPCS codes and drug names to prevent processing delays

Denial Risk

Denial Risk if Precertification Not Obtained

Claims may be denied if precertification is not obtained or if required documentation is missing. To avoid denial risk, secure prior authorization before service and submit complete documentation with the precertification request.

Potential denials for lack of prior authorization for Medicare Part B drugs listed (effective 07/01/2022)

Definitions

inv-09: Medicare Part B specialty drugs — physician-administered drugs billed under HCPCS (J/C codes) subject to Anthem precertification

DefinitionMedicare Part B specialty drugs are physician‑administered drugs billed under HCPCS codes (e.g., J‑codes, C‑codes) that are included in Anthem's specialty pharmacy precertification review.

ScopeApplies to the specific Medicare Part B specialty drugs listed (Fyarro, Besremi, Vyvgart, Adbry, Legvio) for dates of service on or after July 1, 2022.

Billing CodesAssociated HCPCS codes referenced for these drugs include J3490, J3590, and C9399 as listed in the policy.

Precertification RequirementThese physician‑administered Medicare Part B specialty drugs are subject to Anthem precertification review under the specialty pharmacy program effective July 1, 2022.

PrecedenceFederal and state law, state contract language, and CMS guidelines (including definitions and contract provisions/exclusions) take precedence when determining coverage.

OpenPayer

Specialty pharmacy precertification list expansion — Medicare Part B drugs

Coverage / Policy Criteria

Billing Codes

Provider Responsibilities & Actions

Background & Purpose

Definitions