MP/CG Update/Notice - May 2022 Form

P.O. Box 4330 Woodland Hills, CA 91365 2152-0522-DM-CA

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.

May 1, 2022

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with Specialty Pharmacy and MCG updates. Please refer to the specific policy for coding, language, rationale updates and changes that are not summarized below.

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

Updates to AIM Specialty Health® (AIM) programs, a separate company, apply to local fully insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by AIM. They do not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program® (FEP®). For more information, please contact the phone number of the back of the member ID card.

Specialty Pharmacy updates

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.

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.

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

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 for your patients in order to review for continued use of these medications.

Effective for dates of service on and after August 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Clinical Criteria Drug HCPCS Code(s) ING-CC-0062 Yusimry (adalimumab-aqvh) J3590 ING-CC-0072 Vabysmo (faricimab-svoa) J3490, J3590 ING-CC-0210 Enjaymo (sutimlimab-jome) C9399, J3490, J3590, J9999 ING-CC-0211* Kimmtrak (tebentafusp-tebn) C9399, J3490, J3590, J9999 ING-CC-0212 Tezspire (tezepelumab-ekko) C9399, J3590 ING-CC-0213 Voxzogo (vosoritide) C9399, J3490

* Oncology use is managed by AIM.

2152-0522-DM-CA

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.

Step therapy updates

Effective for dates of service on and after August 1, 2022, the following specialty pharmacy code from current clinical criteria will be removed from our existing specialty pharmacy medical step therapy review process.

Clinical Criteria Status Drug HCPCS Code(s) ING-CC-0072 Non-Preferred Vabysmo (faricimab-svoa) J3490, J3590 Quantity limit updates

Effective for dates of service on and after August 1, 2022, the following specialty pharmacy code from current clinical criteria will be included in our quantity limit review process.

Clinical Criteria Drug HCPCS Code(s) ING-CC-0062 Hulio (adalimumab-fkjp) J3590 ING-CC-0062 Ixifi (infliximab-qbtx) Q5109 ING-CC-0062 Yusimry (adalimumab-aqvh) J3590 ING-CC-0072 Vabysmo (faricimab-svoa) J3490, J3590 ING-CC-0210 Enjaymo (sutimlimab-jome) C9399, J3490, J3590, J9999 ING-CC-0212 Tezspire (tezepelumab-ekko) C9399, J3590 ING-CC-0213 Voxzogo (vosoritide) C9399, J3490

MCG Care Guideline 26th Edition update

In our April 1, 2022, letter we notified you that effective July 1, 2022, we will upgrade to the 26th Edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CCG), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). In addition, we adopted two new modules: Hospital-at- Home and Observation Care. Please note that the effective date for use of this criteria has been moved to
September 1, 2022.

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