MP/CG Update/Notice - February 2023 Form

P.O. Box 4330 Woodland Hills, CA 91365

• AIM Specialty Health is an independent company providing some utilization review 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-016914-23-CPN16708

  January 2023

  February 1, 2023

  Subject: Anthem Blue Cross prior authorization updates for specialty pharmacy drugs

  Dear Provider:

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

  The Medical Specialty Drug Review team for Anthem manages prior authorization clinical review of non- oncology use of specialty pharmacy drugs. AIM Specialty Health®* (AIM), a separate company, manages review of specialty pharmacy drugs for oncology.

  Updates to AIM programs 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 Federal Employee Program® (FEP). For more information, please contact the phone number of the back of the member ID card.

  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 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.

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

  Reminder: Clinical Criteria name change — In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC-XXXX; however, the content within the documents remains unchanged.

  Prior authorization updates Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

  Clinical Criteria Drug HCPCS or CPT Code(s) CC-0226 Elahere (mirvetuximab) J3590, J9999 CC-0223 Imjudo (tremelimumab-actl) J3490, J3590, J9999 CC-0224 Pedmark (sodium thiosulfate injection) J3490, J9999 CC-0222 Tecvayli (teclistamab-cqyv) J3490, J3590, J9999 CC-0225 Tzield (teplizumab-mzwv) J3490, J3590

Anthem Blue Cross Anthem prior authorization updates for specialty pharmacy are available Page 2 of 2

CC-0107* Vegzelma (bevacizumab-adcd) J3590, J9999 CC-0072 Vegzelma (bevacizumab-adcd) J3590

• Oncology use is managed by AIM.

  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 May 1, 2023, the following specialty pharmacy codes from current Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

  • CC-0107 Bevacizumab for Non-ophthalmologic Indications: Currently has step therapy preferring Avastin and the biosimilar Mvasi. The new biosimilar, Vegzelma, will be added to existing step therapy as a non-preferred agent.

  Clinical Criteria Status Drug HCPCS or CPT Code(s) CC-0107 Non-preferred Alymsys C9142, J3490, J3590, J9999 CC-0107 Non-preferred Vegzelma J3590, J9999 CC-0107 Non-preferred Zirabev Q5118 CC-0107 Preferred Avastin J9035 CC-0107* Preferred Mvasi Q5107

• Oncology use is managed by AIM.

  • CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors: Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non- preferred to preferred agents.

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

  Clinical Criteria Drug HCPCS or CPT Code(s) CC-0225 Tzield (teplizumab-mzwv) J3490, J3590 CC-0072 Vegzelma (bevacizumab-adcd) J3590

  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