MP/CG Update/Notice - March 2021 Form

P.O. Box 4330 Woodland Hills, CA 91365 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.

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March 1, 2021

Dear Provider:

We have an update and clarification to our message to you about California Senate Bill 855 set forth in our January 1, 2021 medical policy/clinical criteria update.

Update to Our January 1, 2021 Message About California Senate Bill 855

In compliance with CA Senate Bill 855, effective January 1, 2021, Anthem Blue Cross determines the medical necessity of health care services for mental health and substance use disorders, including gender dysphoria, by using generally accepted standards of mental health and substance use disorder care, as cited in non-profit medical societies’ and organizations’ clinical guidelines and level of care criteria. These guidelines and criteria include the American Society of Addiction Medicine (ASAM); Level of Care Utilization System (LOCUS) and Child and Adolescent Level of Care Utilization System (CALOCUS) by the American Association of Community Psychiatrists (AACP); Early Childhood Service Intensity Instrument (ECSII) by the American Academy of Child and Adolescent Psychiatry (AACAP); and the Standards of Care by the World Professional Association for Transgender Health (WPATH).

For members seeking treatment for a primary substance use condition(s) at various levels of care, including professional outpatient mental health, intensive outpatient program (IOP), partial hospitalization program (PHP), residential treatment program (RTC), and acute inpatient psychiatric level of care, we apply the American Society of Addiction Medicine (ASAM) criteria. For members seeking treatment for primarily mental health issues, we apply the LOCUS for members 18 years and older; CALOCUS for members who are 6-17 years of age; ECSII for members who are 0-5 years of age; and, WPATH for gender dysphoria. These changes allow us to enhance collaboration and coordination with treatment providers and facilities who may already be using the above set of guidelines. These guidelines and criteria help us to make determinations regarding services delivered to members in California fully insured plans whether the member is located or receiving services inside or outside of California.

We want to thank you for working with Anthem in moving to our new level of care determination criteria and hope the new change will make determination reviews more expedient, foster a stronger collaboration relationship with providers, and ultimately lead to enhanced care to our members.

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the Anthem website at http://www.anthem.com/ca and then selecting “Providers”, then selecting “Policies, Guidelines & Manuals” under the Provider Resources column, scrolling down to select “View Medical Policies & Clinical UM Guidelines”, then selecting ”Full List page” or by entering a keyword or code in the search box.

Prior authorization updates for Specialty Pharmacy are available

Effective for dates of service on and after June 1, 2021, the following specialty pharmacy codes from new clinical criteria documents will be included in our prior authorization review process.

Clinical criteria information is available at www11.anthem.com/ca/pharmacyinformation/clinicalcriteria.html.

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.

Prior authorization clinical review of non-oncology specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications is managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.

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.

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

Clinical Criteria HCPCS Codes Drug ING-CC-0184 J3490, J3590, J9999 Danyelza (naxitamab-gqgk) ING-CC-0185 C9399, J3490 Oxlumo (lumasiran) Oncology use is managed by AIM.

In our December 1, 2020 notification, we shared that effective April 1, 2021 prior authorization would be required for bortezomib/Velcade (ING-CC-0095). Please be advised that these codes will not be included in our prior authorization process at this time.

Please note the change in date for the implementation of prior authorization and step therapy for injectable iron deficiency anemia products (ING-CC-0182) listed below has been delayed from March 1, 2021 to May 1, 2021.

Clinical Criteria HCPCS Code Drug Status ING-CC-0182 Q0138 Feraheme (ferumoxytol) Non-preferred ING-CC-0182 J2916 Ferrlecit (sodium ferric gluconate complex in sucrose) Preferred ING-CC-0182 J1750 Infed (iron dextran) Preferred ING-CC-0182 J1439 Injectafer (ferric carboxymaltose) Non-preferred ING-CC-0182 J1437 Monoferric Non-preferred ING-CC-0182 J1756 Venofer (iron sucrose) Preferred

In an effort to simplify care and support our providers, we will be removing the prior authorization requirement for the drugs listed below when used to treat ocular conditions, effective May 1, 2021.

Clinical Criteria HCPCS Code Drug
ING-CC-0072 C9257, J9035 Avastin (intravitreal bevacizumab) ING-CC-0072 Q5107 Mvasi (bevacizumab-awwb) ING-CC-0072 Q5118 Zirabev (bevacizumab-bvzr)

Site of Care medical necessity reviews for long-acting colony-stimulating factors – beginning June 1, 2021

Effective with dates of service on or after June 1, 2021, local fully-insured Anthem members will require a medical necessity review of the site of care for the following long-acting colony-stimulating factors for oncology indications: • Neulasta / Neulasta Onpro (pegfilgrastim) • Fulphila (pegfilgrastim-jmdb) • Udenyca (pegfilgrastim-cbqv) • Ziextenzo (pegfilgrastim-bmez) • Nyvepria (pegfilgrastim-apgf)

The review will be administered by AIM Specialty Health® (AIM). AIM will evaluate the clinical information in the request to determine if the hospital-based outpatient setting is medically necessary for the medication administration using CG-MED-83 Site of Care: Specialty Pharmaceuticals. You may contact AIM to request a peer-to-peer discussion before or after the determination.

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.

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The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Review also does not apply when Anthem is the secondary payer.

To submit a request for review Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021, 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 through Friday, 7:00 a.m. – 5:00 p.m. PT.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the member’s ID card.

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