MP/CG Update/Notice - February 2018 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. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

February 1, 2018

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

Dear Provider:

Anthem Blue Cross is pleased to provide you with updates to Medical Policies and Clinical UM Guidelines. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below. Expansion of Specialty Pharmacy Prior Authorization List
Effective for dates of service on and after May 1, 2018, the following specialty pharmacy drugs will be included in our existing pre-service review process for Anthem members who have these services medically managed by AIM Specialty Health® (AIM), a separate company administering the program on behalf of Anthem. For more information go to http://www.aimprovider.com/specialtyrx/FAQ.html to view the FAQs.

Medical Policy or Clinical Guideline Code Drug CG-DRUG-78 J7195 Rebinyn CG-DRUG-78 J7178 Fibryna CG-DRUG-61 C9016, J3490 Triptodur DRUG.00112 J9203 Mylotarg DRUG.00118 J3590, J9999 Aliqopa

Anthem Blue Cross requires the use of clinically equivalent agents in some drug categories. When prescribing a therapy in these categories, please consider using a preferred clinically equivalent agent. Anthem Blue Cross has a process in place to consider requests for continuing members on existing agents. To inquire about this process, please call Anthem Blue Cross Provider Service Department at 1-855-854-1438.

The following clinical guideline has been updated to include the requirement of a clinically equivalent agent effective May 1, 2018.

Clinical Guideline Impacted Agent Clinically Equivalent Agent CG-DRUG-09: Immune Globulin (IG) Therapy Bivigam®, Carimune NF®, Flebogamma®, Gammagard®, Gammagard S/D®, Gammaplex®, Privigen® Gamunex-C® Octagam®

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. The Blue Cross name and symbol are registered marks of the Blue Cross Association. DRUG.00017 Hyaluronan Injections in Joints other than the Knee

Effective for dates of service on and after May 1, 2018, intra-articular injections of hyaluronan for the treatment of pain due to reducing and no-reducing disc displacement disease of temporomandibular joint disorders, will be considered investigational and not medically necessary. No pre-certification or prior authorization for these agents will be required, but review will occur post-service.

The following codes will be subject to post-service review under this medical policy:

Euflexxa J7323 Hyalgan J7321 Supartz J7321 Gel-One J7326 Hymovis J7322 Synvisc J7325 Gel-Syn J7328 Monovisc J7327 Synvisc-One J7325 Genvisc J7320 Orthovisc J7324

Enhancements to AIM Diagnostic Imaging Clinical Appropriateness Guidelines

Beginning with dates of service on and after May 1, 2018, the following enhancements will apply to AIM Diagnostic Imaging Clinical Appropriateness Guidelines for Anthem members who have these services medically managed by AIM.

Expanded indications for use of Fractional Flow Reserve (FFR) have been added to the guidelines that incorporate the most recent literature regarding the use of Coronary CT Angiography (CCTA) (with or without FFR) as a first-line test in patients with suspected coronary artery disease.

Ordering and servicing providers may submit pre-certification requests to AIM in one of the following ways:

• Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization. • Access AIM via the Availity Web Portal at availity.com • Call the AIM Contact Center toll-free number: 1-877-291-0360, Monday – Friday, 7:00 a.m. – 5:00 p.m. For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines at http://www.aimspecialtyhealth.com/PDF/Guidelines/2018/Jan01/AIM_Guidelines_Cardiac.pdf

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,

Jacob Asher, MD Vice President and Chief Medical Officer