Clinical UM Guidelines adopted by Anthem Blue Cross (PPO) Form

State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CG-ANC-04 Ambulance Services: Air and Water prior to 1/1/16 12/1/2019 CA PPO CG-BEH-14 Intensive In-Home Behavioral Health Services 7/1/2016 2/27/2019 CA PPO CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome 6/28/2018 2/27/2019 CA PPO CG-DME-06 Compression Devices for Lymphedema 5/1/2026 CA PPO CG-DME-10 Durable Medical Equipment prior to 1/1/16 2/27/2019 CA PPO CG-DME-31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) 10/1/2013 4/1/2018 CA PPO CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance 5/1/2018 2/27/2019 CA PPO CG-DME-45 Ultrasound Bone Growth Stimulation 9/20/2018 8/1/2019 CA PPO CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting 12/1/2019 1/1/2020 CA PPO CC-0001 Erythropoiesis Stimulating Agents prior to 1/1/16 2/1/2010 CA PPO CC-0002 Colony Stimulating Factor Agents prior to 1/1/16 8/1/2020 Clinical UM PPO Guidelines for California NOTE: Any C linical Utilization Management (UM) Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered adopted for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are adopted for those purposes. Certain items and/or criteria referenced in this document apply to local fully-insured Anthem Blue Cross members and select members who are covered under self-insured (ASO) benefit plans with services medically managed as part of a purchased program. It does not apply to BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®). The provider will be notified upon requesting precertification if precertification is required for the member. If the program has not been purchased, precertification is not required and clinical review will not be performed for the member. For more information, please contact the phone number of the back of the member ID card.

      California | Anthem Blue Cross | Commercial

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Commercial coverage provided by Anthem Blue Cross, 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. CA-BC-CM-009920-26-S2840 | April 2026

Clinical UM PPO Guidelines for California Page 2 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CC-0003 Immunoglobulins prior to 1/1/16 7/1/2020 CA PPO CC-0004 H.P. Acthar Gel (repository corticotropin injection) 6/1/2013 5/1/2019 CA PPO CC-0006 Hyaluronan Injections 12/1/2017 3/1/2019 CA PPO CC-0007 Synagis (palivizumab) prior to 1/1/17 1/31/2020 CA PPO CC-0009 Lemtrada (alemtuzumab) prior to 1/1/16 3/1/2019 CA PPO CC-0010 Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors 1/15/2016 3/1/2019 CA PPO CC-0011 Ocrevus (ocrelizumab) 9/1/2017 3/1/2019 CA PPO CC-0012 Brineura (cerliponase alfa) 10/1/2017 3/1/2019 CA PPO CC-0013 Mepsevii (vestronidase alfa) 7/1/2018 8/1/2020 CA PPO CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis prior to 1/1/15 3/1/2019 CA PPO CC-0017 Xiaflex (clostridial collagenase histolyticum) injection prior to 1/1/16 3/1/2019 CA PPO CC-0018 Pompe Disease [Lumizyme (alglucosidase alfa), Nexviazyme (avalglucosidase alfa-ngpt), Pombiliti (cipaglucosidase alfa-atga)] prior to 1/1/16 1/31/2020 CA PPO CC-0019 Zoledronic Acid Agents (Reclast) 5/1/2021 CA PPO CC-0020 Natalizumab Agents (Tysabri, Tyruko) 1/1/2017 3/1/2019 CA PPO CC-0021 Fabrazyme (agalsidase beta) 5/1/2017 1/31/2020 CA PPO CC-0022 Vimizim (elosulfase alfa) 5/1/2017 1/31/2020 CA PPO CC-0023 Naglazyme (galsulfase) 5/1/2017 1/31/2020 CA PPO CC-0024 Elaprase (idursufase) 5/1/2017 1/31/2020 CA PPO CC-0025 Aldurazyme (laronidase) 5/1/2017 1/31/2020 CA PPO CC-0027 Denosumab agents 12/28/2017 3/1/2019 CA PPO CC-0028 Benlysta (belimumab) 5/1/2018 1/31/2020 CA PPO CC-0029 Dupixent (dupilumab) 5/1/2018 6/10/2019 CA PPO CC-0031 Intravitreal Corticosteroid Implants 6/28/2018 1/31/2020 CA PPO CC-0032 Botulinum Toxin 9/20/2018 1/31/2020 CA PPO CC-0033 Xolair (omalizumab) 9/20/2018 1/31/2020 CA PPO CC-0034 Hereditary Angioedema Agents 9/20/2018 1/31/2020 CA PPO CC-0035 Duopa (carbidopa and levodopa enteral suspension) 9/20/2018 3/1/2019 CA PPO CC-0037 Kanuma (sebelipase alfa) 9/20/2018 9/1/2019 CA PPO CC-0038 Human Parathyroid Hormone Agents 9/20/2018 3/1/2019 CA PPO CC-0039 GamaSTAN [(immune globulin (human)] prior to 1/1/16 3/1/2019 CA PPO CC-0040 Prialt (ziconotide) prior to 1/1/16 3/1/2019 CA PPO CC-0041 Complement Inhibitors prior to 1/1/16 8/1/2020 CA PPO CC-0042 Monoclonal Antibodies to Interleukin-17 1/15/2016 7/1/2020 CA PPO CC-0043 Monoclonal Antibodies to Interleukin-5 5/1/2016 8/1/2020

Clinical UM PPO Guidelines for California Page 3 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CC-0044 Exondys 51 (eteplirsen) 3/1/2017 3/1/2019 CA PPO CC-0045 Increlex (mecasermin) 10/1/2016 9/1/2019 CA PPO CC-0046 Zinplava (bezlotoxumab) 5/1/2017 3/1/2019 CA PPO CC-0048 Spinraza (nusinersen) 5/1/2017 2/1/2010 CA PPO CC-0049 Radicava (edaravone) 10/1/2017 8/1/2020 CA PPO CC-0050 Monoclonal Antibodies to Interleukin-23 1/1/2018 8/1/2020 CA PPO CC-0051 Enzyme Replacement Therapy for Gaucher Disease prior to 1/1/16 1/31/2020 CA PPO CC-0057 Krystexxa (pegloticase) 1/1/2017 9/1/2019 CA PPO CC-0058 Octreotide Agents 1/15/2016 9/1/2020 CA PPO CC-0061 GnRH Analogs for the Treatment of Non-Oncologic Indications 7/1/2017 1/31/2020 CA PPO CC-0062 Tumor Necrosis Factor Antagonists 12/28/2017 8/1/2020 CA PPO CC-0063 Ustekinumab 12/28/2017 7/1/2020 CA PPO CC-0064 Interleukin-1 Inhibitors 12/28/2017 3/1/2019 CA PPO CC-0065 Agents for Hemophilia and von Willebrand Syndrome 12/28/2017 8/1/2020 CA PPO CC-0066 Monoclonal Antibodies to Interleukin-6 12/28/2017 1/31/2020 CA PPO CC-0067 Prostacyclin Infusion and Inhalation Therapy 5/1/2018 3/1/2019 CA PPO CC-0068 Growth Hormone 5/1/2018 9/1/2019 CA PPO CC-0069 Egrifta (tesamorelin) 5/1/2018 9/1/2019 CA PPO CC-0071 Entyvio (vedolizumab) 5/1/2018 1/31/2020 CA PPO CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors 6/28/2018 7/1/2020 CA PPO CC-0073 Alpha-1 Proteinase Inhibitor Therapy 6/28/2018 1/31/2020 CA PPO CC-0074 Akynzeo (fosnetupitant and palonosetron) for injection 5/1/2019 5/1/2019 CA PPO CC-0075 Rituximab agents for Non-Oncologic Indications 6/28/2018 2/1/2020 CA PPO CC-0076 Nulojix (belatacept) 6/28/2018 3/1/2019 CA PPO CC-0077 Palynziq (pegvaliase-pqpz) 5/1/2019 5/1/2019 CA PPO CC-0078 Orencia (abatacept) 9/20/2018 3/1/2019 CA PPO CC-0079 Strensiq (asfotase alfa) 9/20/2018 3/1/2019 CA PPO CC-0081 Crysvita (burosumab-twza) 5/1/2019 2/1/2010 CA PPO CC-0082 Onpattro (patisiran) 5/1/2019 8/1/2020 CA PPO CC-0085 Actimmune (interferon gamma-1b) 6/28/2018 9/1/2019 CA PPO CC-0086 Spravato (esketamine) Nasal Spray 9/1/2019 CA PPO CC-0087 Gamifant (emapalumab-lzsg) 9/1/2019 CA PPO CC-0088 Elzonris (tagraxofusp-erzs) 9/1/2019 1/31/2020 CA PPO CC-0089 Mozobil (plerixafor) 12/28/2017 6/10/2019 CA PPO CC-0090 Ixempra (iIxabepilone) 6/28/2018 9/1/2019

Clinical UM PPO Guidelines for California Page 4 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CC-0092 Adcetris (brentuximab) 9/20/2018 6/10/2019 CA PPO CC-0094 Pemetrexed Agents (Alimta, Pemfexy) prior to 1/1/16 6/10/2019 CA PPO CC-0096 Asparagine Specific Enzymes prior to 1/1/16 2/1/2022 CA PPO CC-0098 Doxorubicin Liposome (Doxil, Lipodox) 1/1/2017 9/1/2019 CA PPO CC-0099 Abraxane (paclitaxel, protein-bound) 1/1/2017 9/1/2019 CA PPO CC-0100 Istodax (romidepsin) 1/1/2017 9/1/2019 CA PPO CC-0104 Levoleucovorin Agents 5/1/2017 6/10/2019 CA PPO CC-0105 Vectibix (panitumumab)
12/27/2017 6/10/2019 CA PPO CC-0106 Erbitux (cetuximab) 6/28/2018 2/1/2010 CA PPO CC-0107 Bevacizumab for Non-ophthalmologic Indications 7/1/2022 CA PPO CC-0108 Halaven (eribulin) 12/28/2017 9/1/2019 CA PPO CC-0109 Zaltrap (ziv-aflibercept) 12/28/2017 9/1/2019 CA PPO CC-0110 Pertuzumab Agents 12/27/2017 6/10/2019 CA PPO CC-0111 Nplate (romiplostim) 12/28/2017 9/1/2019 CA PPO CC-0112 Xofigo (Radium Ra 223 Dichloride) 12/28/2017 9/1/2019 CA PPO CC-0114 Jevtana (cabazitaxel) 12/28/2017 9/1/2019 CA PPO CC-0115 Kadcyla (ado-trastuzumab) 6/28/2018 6/10/2019 CA PPO CC-0116 Bendamustine Hydrochloride 6/28/2018 6/10/2019 CA PPO CC-0117 Empliciti (elotuzumab) 6/28/2018 9/1/2019 CA PPO CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy 9/1/2019 2/1/2023 CA PPO CC-0119 Yervoy (ipilimumab)
prior to 1/1/16 6/10/2019 CA PPO CC-0120 Kyprolis (carfilzomib)
prior to 1/1/16 6/10/2019 CA PPO CC-0121 Gazyva (obinutuzumab) 9/1/2019 CA PPO CC-0122 Arzerra (ofatumumab)
prior to 1/1/16 6/10/2019 CA PPO CC-0123 Cyramza (ramucirumab)
prior to 1/1/16 6/10/2019 CA PPO CC-0124 Keytruda (pembrolizumab)
prior to 1/1/16 6/10/2019 CA PPO CC-0125 Opdivo (nivolumab)
prior to 1/1/16 6/10/2019 CA PPO CC-0126 Blincyto (blinatumomab) 9/1/2019 CA PPO CC-0127 Darzalex (daratumumab) 9/1/2019 CA PPO CC-0128 Atezolizumab (Tecentriq, Tecentric Hybreza) 9/1/2019 CA PPO CC-0129 Bavencio (avelumab)
10/1/2017 6/10/2019 CA PPO CC-0130 Imfinzi (durvalumab) 9/1/2019 CA PPO CC-0131 Besponsa (inotuzumab ozogamicin) 1/1/2018 9/1/2019 CA PPO CC-0132 Mylotarg (gemtuzumab ozogamicin) 9/1/2019 CA PPO CC-0133 Aliqopa (copansilib) 9/1/2019

Clinical UM PPO Guidelines for California Page 5 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CC-0134 Provenge (sipuleucel-T) 9/1/2019 CA PPO CC-0135 Melanoma Vaccines 9/1/2019 CA PPO CC-0136 Drug Dosage, Frequency and Route of Administration 9/1/2017 9/1/2019 CA PPO CC-0137 Cablivi (caplacizumab-yhdp ) 12/1/2019 CA PPO CC-0139 Evenity (romosozumab-aqqg) 12/1/2019 CA PPO CC-0140 Zulresso (brexanolone) 12/1/2019 CA PPO CC-0141 Off-Label Drug and Approved Orphan Drug Use prior to 1/1/16 9/1/2019 CA PPO CC-0142 Somatuline Depot (lanreotide) 2/1/2020 CA PPO CC-0143 Polivy (polatuzumab vedotin-piiq) 2/1/2020 CA PPO CC-0145 Libtayo (cemiplimab-rwlc) 2/1/2020 CA PPO CC-0148 Agents for Hemophilia B 4/1/2020 CA PPO CC-0149 Select Clotting Agents for Bleeding Disorders 4/1/2020 CA PPO CC-0150 Kymriah (tisagenlecleucel) 2/5/2020 CA PPO CC-0151 Yescarta (axicabtagene ciloleucel) 2/5/2020 CA PPO CC-0152 Vyondys 53 (golodirsen) 7/1/2020 CA PPO CC-0153 Adakveo (crizanlizumab 7/1/2020 CA PPO CC-0154 Givlaari (givosiran) 7/1/2020 CA PPO CC-0155 Ethyol (amifostine) 8/1/2020 CA PPO CC-0156 Reblozyl (luspatercept) 8/1/2020 CA PPO CC-0157 Padcev (enfortumab vedotin) 8/1/2020 CA PPO CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki) 8/1/2020 CA PPO CC-0159 Scenesse (afamelanotide) 8/1/2020 CA PPO CC-0160 Vyepti (eptinezumab) 8/1/2020 CA PPO CC-0161 Sarclisa (isatuximab-irfc) 9/1/2020 CA PPO CC-0162 Tepezza (teprotumumab-trbw) 10/1/2020 CA PPO CC-0163 Durysta (bimatoprost implant) 10/1/2020 CA PPO CC-0164 Jelmyto (mitomycin gel) 12/1/2020 CA PPO CC-0165 Trodelvy (sacituzumab govitecan) 12/1/2020 CA PPO CC-0166 Trastuzumab Agents 7/1/2022 CA PPO CC-0167 Rituximab Agents for Oncologic Indications 2/1/2022 CA PPO CC-0168 Tecartus (brexucabtagene autoleucel) 1/1/2021 CA PPO CC-0169 Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf) 1/1/2021 CA PPO CC-0170 Uplizna (inebilizumab-cdon) 1/1/2021 CA PPO CC-0171 Zepzelca (lurbinectedin) 1/1/2021 CA PPO CC-0172 Viltepso (viltolarsen) 1/1/2021 CA PPO CC-0173 Enspryng (satralizumab-mwge) 1/1/2021 CA PPO CC-0174 Kesimpta (ofatumumab) 1/1/2021

Clinical UM PPO Guidelines for California Page 6 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CC-0175 Proleukin (aldesleukin) 1/1/2021 CA PPO CC-0176 Beleodaq (belinostat) 1/1/2021 CA PPO CC-0177 Zilretta (triamcinolone acetonide extended-release) 1/1/2021 CA PPO CC-0178 Synribo (omacetaxine mepesuccinate) 1/1/2021 CA PPO CC-0180 Monjuvi (tafasitamab-cxix) 3/1/2021 CA PPO CC-0182 Iron Agents 5/1/2021 CA PPO CC-0184 Danyelza (naxitamab-gqgk) 6/1/2021 CA PPO CC-0185 Oxlumo (lumasiran) 6/1/2021 CA PPO CC-0186 Margenza (margetuximab-cmkb) 8/1/2021 CA PPO CC-0187 Breyanzi (lisocabtagene maraleucel) 8/1/2021 CA PPO CC-0188 Imcivree (setmelanotide) 8/1/2021 CA PPO CC-0189 Amondys 45 (casimersen) 8/1/2021 CA PPO CC-0190 Nulibry (fosdenopterin) 8/1/2021 CA PPO CC-0192 Cosela (trilaciclib) 9/1/2021 CA PPO CC-0193 Evkeeza (evinacumab) 9/1/2021 CA PPO CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) 10/1/2021 CA PPO CC-0195 Abecma (idecabtagene vicleucel) 10/1/2021 CA PPO CC-0196 Zynlonta (loncastuximab tesirine-lpyl) 11/1/2021 CA PPO CC-0197 Jemperli (dostarlimab) 11/1/2021 CA PPO CC-0199 Empaveli (pegcetacoplan) 11/1/2021 CA PPO CC-0200 Aduhelm (aducanumab-avwa) 9/1/2022 CA PPO CC-0201 Rebrevant (amivantamab-ymoiw) 12/1/2021 CA PPO CC-0202 Saphnelo (anifrolumab-fnia) 2/1/2022 CA PPO CC-0203 Ryplazim (plasminogen, human-tvmh) 2/1/2022 CA PPO CC-0204 Tivdak (tisotumab vedotin-tftv) 6/1/2022 CA PPO CC-0205 Fyarro (sirolimus albumin bound) 6/1/2022 CA PPO CC-0206 BESREMi (ropeginterferon alfa-2b-njft) 6/1/2022 CA PPO CC-0207 Vyvgart (efgartigimod alfa-fcab) 6/1/2022 CA PPO CC-0208 Adbry (tralokinumab) 6/1/2022 CA PPO CC-0209 Leqvio (inclisiran) 6/1/2022 CA PPO CC-0210 Enjaymo (sutimlimab-jome) 8/1/2022 CA PPO CC-0211 Kimmtrak (tebentafusp-tebn) 8/1/2022 CA PPO CC-0212 Tezspire (tezepelumab-ekko) 8/1/2022 CA PPO CC-0213 Voxzogo (vosoritide) 8/1/2022 CA PPO CC-0214 Carvykti (ciltacabtagene autoleucel) 9/1/2022 CA PPO CC-0216 Opdualag (nivolumab and relatlimab-rmbw) 11/1/2022

Clinical UM PPO Guidelines for California Page 7 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CC-0217 Amvuttra (vutrisiran) 12/1/2022 CA PPO CC-0218 Xipere (triamcinolone acetonide injectable suspension) 12/1/2022 CA PPO CC-0220 Xenpozyme (olipudase alfa) 2/1/2023 CA PPO CC-0221 Spevigo (spesolimab-sbzo) 2/1/2023 CA PPO CC-0222 Tecvayli (teclistamab-cqyv) 5/1/2023 CA PPO CC-0223 Imjudo (tremelimumab-actl) 5/1/2023 CA PPO CC-0224 Pedmark (sodium thiosulfate injection) 5/1/2023 CA PPO CC-0225 Tzield (teplizumab-mzwv) 5/1/2023 CA PPO CC-0226 Elahere (mirvetuximab) 5/1/2023 CA PPO CC-0227 Briumvi (ublituximab) 6/1/2023 CA PPO CC-0228 Leqembi (lecanemab) 6/1/2023 CA PPO CC-0230 Adstiladrin (nadofaragene firadenovec-vncg) 8/1/2023 CA PPO CC-0231 Lamzede (velmanase alfa-tycv) 8/1/2023 CA PPO CC-0232 Lunsumio (mosunetuumab-axgb) 8/1/2023 CA PPO CC-0233 Rebyota (fecal microbiota, live – jslm) 8/1/2023 CA PPO CC-0234 Syfovre (pegcetacoplan) 8/1/2023 CA PPO CC-0235 Revcovi (elapegademase-lvlr) 9/1/2023 CA PPO CC-0236 Signifor LAR (pasireotide) 9/1/2023 CA PPO CC-0237 Qalsody (tofersen) 11/1/2023 CA PPO CC-0240 Zynyz (retifanlimab-dlwr) 1/1/2024 CA PPO CC-0241 Elfabrio (pegunigalsidase alfa-iwxj) 12/1/2023 CA PPO CC-0242 Epkinly (epcoritamab-bysp) 1/1/2024 CA PPO CC-0243 Vyjuvek (beremagene geperpavec) 12/1/2023 CA PPO CC-0244 Columvi (glofitamab-gxbm) 1/1/2024 CA PPO CC-0245 Izervay (avacincaptad pegol) 1/1/2024 CA PPO CC-0246 Rystiggo (rozanolixizumab-noli) 1/1/2024 CA PPO CC-0247 Beyfortus (nirsevimab) 2/1/2024 CA PPO CC-0248 Elrexfio (elranatamab-bcmm) 5/1/2024 CA PPO CC-0249 Talvey (talquetamab-tgvs) 5/1/2024 CA PPO CC-0250 Veopoz (pozelimab-bbfg) 5/1/2024 CA PPO CC-0251 Ycanth (cantharidin) 5/1/2024 CA PPO CC-0252 Adzynma (ADAMTS13, recombinant-krhn) 5/1/2024 CA PPO CC-0253 Aphexda (motixafortide) 5/1/2024 CA PPO CC-0254 Zilbrysq (zilucoplan) 5/1/2024 CA PPO CC-0255 Loqtorzi (toripalimab-tpzi) 6/1/2024 CA PPO CC-0256 Rivfloza (nedosiran) 6/1/2024

Clinical UM PPO Guidelines for California Page 8 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CC-0257 Wainua (eplontersen) 6/1/2024 CA PPO CC-0258 iDose TR (travoprost implant) 8/1/2024 CA PPO CC-0259 Amtagvi (lifileucel) 8/1/2024 CA PPO CC-0260 Nexobrid (anacaulase-bcdb) 8/1/2024 CA PPO CC-0261 Winrevair (sotatercept-csrk) 10/1/2024 CA PPO CC-0262 Tevimbra (tislelizumab-jsgr) 11/1/2024 CA PPO CC-0263 Imdelitra (tartlatamab-dlle) 12/1/2024 CA PPO CC-0264 Anktiva (nogapendekin alfa inbekicept-pmln) 12/1/2024 CA PPO CC-0265 Kisunla (donanemab-azbt) 1/1/2025 CA PPO CC-0266 Rytelo (imetelstat) 2/1/2025 CA PPO CC-0267 Ebglyss (lebrikizumab-lbkz) 3/1/2025 CA PPO CC-0268 Lymphir (denileukin diftitox-cxdl) 3/1/2025 CA PPO CC-0269 Nemluvio (nemolizumab-ilto) 3/1/2025 CA PPO CC-0270 Niktimvo (axatilmab-csfr) 3/1/2025 CA PPO CC-0271 Tecelra (afamitresgene autoleucel) 3/1/2025 CA PPO CC-0272 Aucatzyl (obecabtagene autoleucel) 7/1/2025 CA PPO CC-0273 Vyloy (zolbetuximab-clzb) 7/1/2025 CA PPO CC-0274 Bizengri (zenocutuzumab-zbco) 7/1/2025 CA PPO CC-0275 Ziihera (zanidatamab-hrii) 7/1/2025 CA PPO CC-0276 Tryngolza (olezarsen) 7/1/2025 CA PPO CC-0277 Vyalev (foscarbidopa/foslevodopa) 11/1/2025 CA PPO CC-0278 Unloxcyt (cosibelimab-ipdl) 12/1/2025 CA PPO CC-0279 Datroway (datopotamab deruxtecan-dlnk) 12/1/2025 CA PPO CC-0280 Grafapex (treosulfan) 12/1/2025 CA PPO CC-0281 Opdivo Qvantig (nivolumab hyaluronidase-nvhy) 12/1/2025 CA PPO CC-0282 Onapgo (apomorphine subcutaneous solution) 12/1/2025 CA PPO CC-0283 Imaavy (nipocalimab-aahu) 11/1/2025 CA PPO CC-0284 Emrelis (telisotuzumab vedotin-tllv) 12/1/2025 CA PPO CC-0285 Penpulimab-kcqx 12/1/2025 CA PPO CC-0286 Lynozyfic (linvoseltamab-gcpt) 2/1/2026 CA PPO CC-0287 Zusduri (mitomycin intravesical solution) 2/1/2026 CA PPO CC-0288 Enflonsia (clesrovimab-cfor) 2/1/2026 CA PPO CC-0290 Papzimeos (zopapogene imadenovec-drba) 2/1/2026 CA PPO CC-0292 Forzinity (elamipretide) 5/1/2026 CA PPO CC-0293 Inlexzo (gemcitabine intravesical system) 5/1/2026 CA PPO CG-MED-19 Custodial Care prior to 1/1/16 12/12/2018 CA PPO CG-MED-26 Neonatal Levels of Care prior to 1/1/16 12/15/2018 CA PPO CG-MED-65 Manipulation Under Anesthesia 12/28/2017 1/1/2019 CA PPO CG-MED-69 Inhaled Nitric Oxide 6/28/2018 10/1/2020 CA PPO CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) 9/20/2018 3/1/2019

Clinical UM PPO Guidelines for California Page 9 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications prior to 1/1/16 5/9/2019 CA PPO CG-MED-83 Site of Care: Specialty Pharmaceuticals 7/1/2016 10/1/2020 CA PPO CG-MED-88 Preimplantation Embryo Biopsy 1/1/2022 CA PPO CG-MED-89 Home Parenteral Nutrition 11/1/2021 CA PPO CG-MED-97 Biofeedback and Neurofeedback 12/1/2024 CA PPO CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease 1/30/2025 CA PPO CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine 4/16/2025 CA PPO CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient) prior to 1/1/16 12/15/2018 CA PPO CG-REHAB-08 Private Duty Nursing in the Home Setting prior to 1/1/16 10/1/2020 CA PPO CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift prior to 1/1/16 1/24/2019 CA PPO CG-SURG-18 Septoplasty prior to 1/1/16 6/6/2018 CA PPO CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver 12/28/2017 2/5/2020 CA PPO CG-SURG-71 Reduction Mammaplasty 5/1/2018 5/1/2018 CA PPO CG-SURG-78 Cryosurgical, Radiofrequency, Microwave, or Percutaneous Ethanol Ablation to Treat Solid Tumors in the Liver 6/28/2018 4/1/2020 CA PPO CG-SURG 79 Implantable Infusion Pumps 6/28/2018 10/1/2019 CA PPO CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants 9/20/2018 8/1/2019 CA PPO CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity 10/31/2018 10/1/2020 CA PPO CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery 9/20/2018 9/20/2018 CA PPO CG-SURG-88 Mastectomy for Gynecomastia 9/20/2018 9/20/2018 CA PPO CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence and Fecal Incontinence 3/21/2019 4/16/2025 CA PPO CG-SURG-99 Panniculectomy and Abdominoplasty prior to 1/1/16 5/9/2019 CA PPO CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus prior to 1/1/16 9/4/2019 CA PPO CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone 2/5/2020 7/1/2020 CA PPO CG-SURG-117 Balloon Dilation of the Eustacian Tube 4/12/2023 CA PPO CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) 4/10/2024 CA PPO CG-SURG-120 Vagus Nerve Stimulation 4/10/2024 CA PPO CG-SURG-131 Transcatheter Aortic Heart Valve Procedures 4/15/2026

Clinical UM PPO Guidelines for California Page 10 of 12 State CG number CG title CG Category Original implementation Date Current Version Implementation Date Special Notes CA PPO CG-SURG-132 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia, or Gastroparesis 4/15/2026 CA PPO CG-SURG-133 Intraluminal Left Atrial Appendage Closure Devices 4/15/2026 CA PPO CG-SURG-125 Canaloplasty 1/30/2025 CA PPO CG-TRANS-02 Kidney Transplantation prior to 1/1/16 4/25/2018 CA PPO CG-TRANS-04 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation 4/15/2026 CA PPO American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for the assessment and treatment of children and adolescents with autism spectrum disorder 8/1/2025 California Self-insured (ASO) benefit plans use MCG B-806-T Behavioral Health Care Applied Behavioral Analysis CA PPO Canadian Network for Mood and Anxiety Treatment (CANMAT) Transcranial Magnetic Stimulation 8/1/2025 California Self-insured (ASO) benefit plans use MCG B-801-T Transcranial Magnetic Stimulation CA PPO The World Professional Association for Transgender Health Standards of Care for the Health of Transgender and Gender Diverse People 1/1/2021 9/15/2022 State Implementation Date Notes 12/17/2018 4/1/2023 10/1/2024 11/7/2021 9/1/2016 9/1/2016 CA PPO CA PPO Program and Criteria Carelon Radiation Oncology - Clinical Appropriateness Guidelines are available at: In addition to the Anthem Clinical UM Guidelines noted above, the health plan uses Clinical Appropriateness Guidelines developed by Carelon Medical Benefits Management, Inc. For certain health plan members, Carelon also provides select utilization management services. Carelon Musculoskeletal - Clinical Appropriateness Guidelines are available at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/ Prior Authorization review for select accounts using the Anthem Clinical UM Guideline noted below. CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia Radiation Therapy (excludes Proton) Perirectal Hydrogel Spacer for Prostate Radiotherapy Proton Beam Therapy

Clinical UM PPO Guidelines for California Page 11 of 12 State Implementation Date Notes CA PPO < 2016 1/1/2019 1/1/2019 2/18/2017 4/1/2025 6/1/2024 1/1/2019 4/1/2025 4/1/2025 6/1/2024 6/1/2024 1/1/2019 6/1/2024 4/1/2025 4/1/2025 11/15/2025 7/25/2025 Prior Authorization review for select accounts using the Anthem Clinical UM Guideline noted below. 6/1/2024 < 2016 < 2016 < 2016 < 2016 < 2016 < 2016 < 2016 < 2016 < 2016 6/1/2024 < 2016 4/1/2024 CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures CA PPO Cardiac Resynchronization Therapy Diagnostic Coronary Angiography Dialysis Access Evaluations Electrophysiological Studies Endovascular Revascularization Vascular Imaging Carelon Radiology/Diagnostic Imaging - Clinical Appropriateness Guidelines are available at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/ Site of Care for Advanced Imaging CG-SURG-29 Lumbar Discography Prior Authorization review for select accounts using the Anthem Clinical UM Guideline noted below. Vascular Embolization and Occlusion Procedures CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction Carelon Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures and Upper Gastrointestinal Endoscopy in Adults - Prior Authorization review for select accounts using the Anthem Clinical UM Guideline noted below. CG-MED-59 Upper Gastrointestinal Endoscopy in Adults Implantable Cardioverter Defibrillators CA PPO Ambulatory Cardiac Rhythm Monitoring Imaging of the Heart Imaging of the Spine Oncologic Imaging Imaging of the Abdomen and Pelvis Imaging of the Brain Imaging of the Chest Imaging of the Extremities Imaging of the Head and Neck Program and Criteria Transcatheter Ablation for Management of Supraventricular and Ventricular Arrhythmias Carelon Sleep Disorder Management - Clinical Appropriateness Guidelines available at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-sleep-guidelines/ Carelon Cardiovascular - Clinical Appropriateness Guidelines are available at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiology-guidelines/ Treatment of Varicose Veins and Superficial Venous Insufficiency Percutaneous Coronary Intervention Permanent Implantable Pacemakers Transcatheter Ablation for Management of Atrial Fibrillation

Clinical UM PPO Guidelines for California Page 12 of 12 State Implementation Date Notes 8/1/2025 3/1/2025 3/1/2025 5/1/2024 3/1/2025 3/1/2025 3/1/2025 3/1/2025 3/1/2025 3/1/2025 3/1/2025 4/1/2024 3/1/2025 1/30/2025 4/16/2025 5/1/2025 7/1/2025 6/1/2024 11/15/2025 Carelon Genetic Testing - Clinical Appropriateness Guidelines are available at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-genetic-testing-guidelines/ CA PPO CA PPO CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI) CA PPO Carelon Surgical Procedures - Prior Authorization review for select accounts using the Anthem Clinical UM Guideline noted below. Surgical Procedure checklist is available at https://providers.carelonmedicalbenefitsmanagement.com/surgicalprocedures/resources CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems CA PPO Program and Criteria CG-SURG-92 Paraesophageal Hernia Repair CG-SURG-105 Corneal Collagen Cross-Linking CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses CG-SURG-09 Temporomandibular Disorders CG-SURG-12 Penile Prosthesis Implantation CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) CG-SURG-73 Balloon Sinus Ostial Dilation CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids CG-SURG-126 Tibial Nerve Stimulation CG-SURG-129 Internal Rib Fixation Systems Carelon Surgical Procedures - Clinical Appropriateness Guidelines available at: CG-MED-68 Therapeutic Apheresis Site of Care for Surgical Procedures Level of Care for Surgical Procedures Carelon Additional Outpatient Utilization Management Prior Authorization review for select accounts using the Anthem Clinical UM Guideline noted below. Note: Effective July 1, 2022, in compliance with California SB 535, Anthem Blue Cross and its delegated entities regulated by the California Department of Managed Health Care and the California Department of Insurance will no longer require prior authorization for biomarker testing, including biomarker testing for cancer progression and recurrence, for members with advanced or metastatic stage 3 or 4 cancer, Post service review of medical necessity for biomarker testing for advanced or metastatic stage 3 or 4 cancer members is not permitted, only confirmation of advanced or metastatic stage 3 or 4 cancer is permitted.