MP/CG Update/Notice - June 2020 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.

458-0620-DM-CA

June 1, 2020

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

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with our new and updated Clinical Criteria.

Prior authorization updates

Effective for dates of service on and after September 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Clinical Criteria is available at https://www11.anthem.com/ca/pharmacyinformation/clinicalcriteria.html.

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

Pre-service clinical review of non-oncology specialty pharmacy drugs is managed by Anthem’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology indications is managed by AIM Specialty Health® (AIM), a separate company and are shown in italics.

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0161 C9399 J3490 J3590 J9999 Sarclisa *ING-CC-0058 J2354 Bynfezia

• Non-oncology use is managed by Anthem’s Medical Specialty Drug Review team. Oncology use is managed by AIM.

  Step therapy updates

  Effective for dates of service on and after September 1, 2020, the following specialty pharmacy codes from current clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
  The Step Therapy drug list is available at https://www11.anthem.com/provider/noapplication/f0/s0/t0/pw_g350513.pdf.

  Clinical Criteria Status Drug(s) HCPCS Code(s) ING-CC-0003 Non-preferred Panzyga J1599 ING-CC-0003 Non-preferred Xembify J3490

  In addition, please note that THER-RAD.00009 Intraocular Epiretinal Brachytherapy was archived effective April 15, 2020.

  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