MP/CG Update/Notice - November 2019 Form

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. November 1, 2019

[Provider Name]
[Address] [City], [State] [Zip]

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with updated Medical Policies, Clinical UM Guidelines and Clinical Criteria. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

Effective date update

The October 1, 2019 provider letter included notification that CG-SURG-80 (Transcatheter Arterial Chemo- embolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors) and CG-THER-RAD-04 Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors are being archived and added to CG-SURG-78 Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies. Please note the effective date has been moved from November 20, 2019 to November 12, 2019.

Prior Authorization updates for specialty pharmacy drugs

Effective for dates of service on and after February 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

Anthem Blue Cross prior authorization clinical review of non-oncology specialty pharmacy drugs is managed by the Medical Specialty Drug review team. Drugs used for the treatment of oncology are managed by AIM Specialty Health® (AIM), a separate company, and are in italics.

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, Federal Employee Program® (FEP®). For more information, please contact the phone number of the back of the member ID card.

Clinical criteria document information is available at www11.anthem.com/ca/pharmacyinformation/clinicalcriteria.html.

Clinical Criteria

Title HCPCS or CPT Code(s) Drug ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists Q5118 Zirabev ING-CC-0075 Rituximab agents for Non-Oncologic Indications Q5115 Truxima ING-CC-0075 Rituximab agents for Non-Oncologic Indications J3490 Ruxience ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications Q5118 Zirabev ING-CC-0142 Somatuline Depot (lanreotide) J1930 Somatuline Depot ING-CC-0143 Polivy (polatuzumab vedotin-piiq) C9399, J9999 Polivy ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk) J9313 Lumoxiti ING-CC-0145 Libtayo (cemiplimab-rwlc) J9119 Libtayo

• Non-oncology use is managed by the Medical Specialty Drug review team; oncology use is managed by AIM.

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.

Clinical Criteria updates

Effective September 23, 2019, ING-CC-0016 Vivitrol was archived.

Effective for dates of service on and after February 1, 2020, the following current clinical criteria documents will be revised and might result in services that were previously covered but may now be found to be not medically necessary.

 ING-CC-0001 Erythropoiesis Stimulating Agents: Reduced the timeframe for response for the use of Aranesp, Epogen and Procrit for anemia associated with myelosuppressive chemotherapy from 8-9 weeks to 8 weeks.

 ING-CC-0002 Colony Stimulating Factor Agents: Removed medically necessary criteria for the prophylaxis of febrile neutropenia for Leukine.

 ING-CC-0041 Complement Inhibitors: Added medical necessity criteria for Soliris for the new indication of neuromyelitis optica spectrum disorder.

 ING-CC-0048 Spinraza (nusinersen): Updated medical necessity criteria for use after gene therapy to require decline in clinical status.

 ING-CC-0082 Onpattro (patisiran): Added not medically necessary criteria for combination use with other agents for amyloidosis.

 ING-CC-0106 Erbitux (cetuximab): Updated medical necessity criteria for RAS testing to require both KRAS and NRAS wild type.

Quantity Limit updates

Effective January 31, 2020, clinical criteria document ING-CC-0136 Drug dosage, frequency, and route of administration will be archived.

Effective for dates of service on and after February 1, 2020, prior authorization clinical review of drug dosage, frequency and route of administration for the following specialty pharmacy codes from new or current clinical criteria will be based on the quantity limits established in the applicable clinical criteria document. The table below will assist you in identifying the applicable clinical criteria documents and corresponding HCPCS codes.

Prior authorization review of these specialty pharmacy drugs is managed by the Medical Specialty Drug review team.

Clinical Criteria Title Drug(s) HCPCS Code(s) ING-CC-0001 Erythropoiesis Stimulating Agents Aranesp, Epogen, Mircera, Procrit, Retacrit
J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106

ING-CC-0003

Immunoglobulins
Asceniv, Bivigam, Carimune NF, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen

J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599 ING-CC-0007 Synagis (palivizumab) Synagis
90378 ING-CC-0013 Mepsevii (vestronidase alfa) Mepsevii
J3397 ING-CC-0018 Lumizyme (alglucosidase alfa) Lumizyme J0221 ING-CC-0021 Fabrazyme (agalsidase beta)
Fabrazyme
J0180 ING-CC-0022 Vimizim (elosulfase alfa)
Vimizim
J1322 ING-CC-0023 Naglazyme (galsulfase) Naglazyme
J1458 ING-CC-0024 Elaprase (idursufase)
Elaprase
J1743 ING-CC-0025 Aldurazyme (laronidase) Aldurazyme
J1931 ING-CC-0028 Benlysta (belimumab) Benlysta
J0490

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.

ING-CC-0031 Intravitreal Corticosteroid Implants Illuvien, Ozurdex, Retisert, Yutiq J7311, J7312, J7313, J7314 ING-CC-0032 Botulinum Toxin
Botox, Xeomin, Dysport, Myobloc J0585, J0586, J0587, J0588
ING-CC-0033 Xolair (omalizumab)
Xolair
J2357 ING-CC-0034 Agents for Hereditary Angioedema Cinryze, Haegarda, Berinert, Berinert, Firazyr, Ruconest, Kalbitor, Takhzyro J0596, J0597, J0598, J1290, J1744, J0599, J0593 ING-CC-0041 Complement Inhibitors Soliris, Ultomiris J1300, J1303 ING-CC-0043 Monoclonal Antibodies to Interleukin-5
Cinqair, Fasenra, Nucala
J0517, J2182, J2786 ING-CC-0050 Monoclonal Antibodies to Interleukin-23 Tremfya, Ilumya J1628, J3245 ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
Cerezyme, Elelyso, Vpriv
J1786, J3060, J3385 ING-CC-0058 Octreotide Agents
Sandostatin, Sandostatin LAR Depot J2353, J2354 ING-CC-0061 GnRH Analogs for the treatment of non-oncologic indications
Lupron Depot/Depot-Ped J1950, J9217 ING-CC-0062 Tumor Necrosis Factor Antagonists Simponi Aria, Remicade, Inflectra, Renflexis, Ixifi, Humira, Enbrel, Cimzia J1602, J1745, Q5103, Q5104, Q5109, J0135, J1438, J0717 ING-CC-0063 Stelara (ustekinumab)
Stelara
J3357, J3358 ING-CC-0066 Monoclonal Antibodies to Interleukin-6 Actemra
J3262 ING-CC-0071 Entyvio (vedolizumab)
Entyvio
J3380 ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
Avastin, Lucentis, Eylea, Macugen, Zirabev, Mvasi J2503, C9257, J9035, J2778, J0178, Q5118, Q5017 ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy Aralast, Glassia, Prolastin-C, Zemaira J0256, J0257 ING-CC-0075 Rituxan (rituximab) for Non- Oncologic Indications Rituxan, Truxima J9312, Q5115

Coding update

Effective October 1, 2019, INC-CC-0088 Elzonris™ (tagraxofusp-erzs) was updated to reflect the current HCPCS code J9269.

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the Anthem’s Web site at http://www.anthem.com/ca and then hovering over “Providers”, then selecting “Policies and Guidelines” under the Provider Resources column, scrolling down to select “View Medical Policies & UM Guidelines”, then selecting “Medical Policies and Clinical UM Guidelines (for Local Plan members)”, then selecting “Continue” at the bottom of the page.

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