MP/CG Update/Notice - September 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.

September 1, 2019

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

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with our new 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.

NEW Clinical Guideline effective December 1, 2019

• CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs: This document addresses the use of pneumatic compression devices (PCDs) for the prevention of deep vein thrombosis (DVT) of the lower limbs. This document only addresses the home use of pneumatic compression devices post outpatient orthopedic procedures. Prior authorization will be required effective December 1, 2019.

NEW Clinical Criteria effective December 1, 2019

The following Clinical Criteria are new and will require prior authorization effective December 1, 2019. To access the clinical criteria information, go to www11.anthem.com/ca/pharmacyinformation/clinicalcriteria.html.

The non-oncology specialty pharmacy reviews listed below are managed by the medical specialty drug review team.

• ING-CC-0137 Cablivi (caplacizumab-yhdp)
• ING-CC-0139 Evenity (romosozumab-aqqg) • ING-CC-0140 Zulresso (brexanolone)

The oncology specialty drug review listed below is managed by AIM Specialty Health® (AIM), a separate company, and this update applies to local fully-insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by AIM. It does 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.

• ING-CC-0138 Asparlas (calaspargase pegol-mknl)

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. The Blue Cross name and symbol are registered marks of the Blue Cross Association. New drugs added to existing Clinical Criteria

Effective for dates of service on and after December 1, 2019, the following non-oncology specialty pharmacy codes from current clinical criteria 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.

Clinical Criteria HCPCS or CPT Code(s) NDC Code(s) Drug ING-CC-0031 J3490 71879-0136-01 Yutiq™ ING-CC-0003 J3490 J3590 C9399 68982-0810-01 68982-0810-02 68982-0810-03 68982-0810-04 68982-0810-05 68982-0810-06 Cutaquig® ING-CC-0003 J1599 69800-0250-01 Asceniv™

Clinical Criteria updates for specialty pharmacy

Clinical criteria ING-CC-0061 addresses the use of gonadotropin releasing hormone analogs for the treatment of non-oncologic indications. Effective for dates of service on and after December 1, 2019, the use of Zoladex for the treatment of endometriosis will be limited to 6 months.

To access the clinical criteria information please go to www11.anthem.com/ca/pharmacyinformation/clinicalcriteria.html.

Anthem Medical Policies and Clinical UM Guidelines are developed by our Medical Policy and Technology Assessment Committee. The Committee, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments. Medical Policies and Clinical UM Guidelines are subject to the approval of the Physician Relations Committee.

All coverage written or administered by Anthem excludes from coverage services or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set forth in Anthem’s Medical Policies. Review procedures have been refined to facilitate claim investigation.

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the Anthem Web site at http://www.anthem.com/ca and then selecting “Providers”, then “Policies and Guidelines” under the Provider Resources column, scrolling down and selecting “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 Senior Clinical Officer