MP/CG Update/Notice - March 2023 Form

California | Commercial

P.O. Box 4330 Woodland Hills, CA 91365

• 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-019370-23
  February 2023

  March 1, 2023

  Subject: Specialty pharmacy updates for March 2023

  Dear Provider:

  Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by the Anthem Blue Cross medical specialty drug review team.

  Access our Clinical Criteria at https://www.anthem.com/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these site of care updates.

  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 submit a prior authorization review for your patients’ continued use of these medications.

  Including the national drug code on your claim may help expedite claim processing for drugs billed with a not otherwise classified code.

  Prior authorization updates Effective for dates of service on and after June 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-0227 Briumvi (ublituximab) J3490, J3590 CC-0228 Leqembi (lecanemab) J3490, J3590 CC-0229 Sunlenca (lenacapavir) J3490, C9399

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

  Step therapy updates Effective for dates of service on and after January 17, 2023, the following specialty pharmacy codes from new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

  The preferred product in this step therapy is generic dimethyl fumarate.

  Clinical Criteria Status Drug HCPCS or CPT code(s) CC-0227 Non-preferred Briumvi (ublituximab) J3490, J3590

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

Quantity limit updates Effective for dates of service on and after June 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-0227 Briumvi (ublituximab) J3490, J3590 CC-0229 Sunlenca (lenacapavir) J3490, C9399

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