MP/CG Update/Notice - September 2021 Form

P.O. Box 4330 Woodland Hills, CA 91365 752-0821-DM-CA

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, 2021

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

Dear Provider:

Anthem Blue Cross is pleased to provide you with the following updates. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

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, or FEP. For more information, please contact the phone number of the back of the member’s ID card.

Specialty Pharmacy prior authorization updates

Effective for dates of service on and after December 1, 2021, the following specialty pharmacy drugs from new clinical criteria will be included in our prior authorization review process. Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Clinical Criteria is available at https://www.anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html.

Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

• Oncology use is managed by AIM.

  Quantity limit updates

  Effective for dates of service on and after December 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

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

  Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0050 J3490, J3590 Skyrizi (risankizumab-rzaa) ING-CC-0075 Q5123 Riabni (rituximab-arrx)

  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 Clinical Criteria HCPCS or CPT Code(s) Drug *ING-CC-0201 J9999 Rybrevant (amivantamab-ymjw)