MP/CG Update/Notice - August 2023 Form

California | Commercial

• Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
  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.
  CABC-CM-030320-23-CPN29780 July 2023 August 1, 2023

  Subject: Specialty pharmacy updates for August 2023

  Dear Provider:

  Specialty pharmacy updates for Anthem Blue Cross (Anthem) are listed below.

  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 Carelon Medical Benefits Management, Inc.*

  Updates to Carelon Medical Benefits Management 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 Carelon Medical Benefits Management. 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.

  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 review for your patients’ continued use of these medications.

  Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

  Access our Clinical Criteria at anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these updates.

  Prior authorization updates Effective for dates of service on and after November 1, 2023, the following specialty pharmacy codes from new clinical criteria documents will be included in our prior authorization review process.

  Clinical Criteria Drug HCPCS or CPT® code(s) CC-0237 Qalsody (tofersen) J3490, J3590 CC-0240* Zynyz (retifanlimab-dlwr) J9999

• Oncology use is managed by Carelon Medical Benefits Management.

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

Anthem Blue Cross Specialty pharmacy updates for August 2023 Page 2 of 2

Step therapy updates We are excited to announce the publication of a Medical Step Therapy Drug List. This list serves as an easy to access reference of the preferred and non-preferred products for each of the specialty pharmacy step therapy categories. The link to the pdf document is on the Clinical Criteria homepage.

Access our Clinical Criteria at anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html view the Medical Step Therapy Drug List.

Quantity limit updates Effective for dates of service on and after November 1, 2023, the following specialty pharmacy codes from new clinical criteria documents will be included in our quantity limit review process.

Clinical Criteria Drug HCPCS or CPT code(s) CC-0237 Qalsody (tofersen) J3490, J3590 CC-0240 Zynyz (retifanlimab-dlwr) J9999

We thank you for your continued efforts on behalf of our members and your partnership toward improved access to quality healthcare for Californians.

Sincerely,

John Yao, MD, MPH, MBA, MPP, FACP Chief Medical Officer Anthem Blue Cross