MP/CG Update/Notice - May 2021 Form

354-0421-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.

May 1, 2021

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with updated Medical Policies and new and updated Clinical Criteria.
Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.
Please note that we have a correction to a statement made in our March 2021 provider letter.

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan, commonly referred to as the Federal Employee Program® (FEP®), please visit www.fepblue.org > Policies & Guidelines.

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 on the back of the member ID card.

UPDATED Medical Policies effective September 1, 2021

• GENE.00056 Gene Expression Profiling for Bladder Cancer: This document addresses gene expression profiling to diagnose bladder cancer, predict response to therapy in individuals with bladder cancer, and monitor individuals with a history of bladder cancer.
o Prior authorization required for AIM-eligible members effective September 1, 2021

Prior authorization updates

Revision to March 2021 letter:

The March 2021 provider letter advised we would no longer require prior authorization for the following drugs used to treat ocular conditions effective May 1, 2021. This decision has been revised. Please be advised that prior authorization will continue to be required for these drugs. We apologize for any inconvenience.

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) Non-oncology use is managed by Anthem’s medical specialty drug review team.

Effective for dates of service on and after August 1, 2021, the following specialty pharmacy codes from current or 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.

354-0421-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.

Clinical Criteria information is available at https://www.anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM.

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0075 J3590, J9999, C9399 Riabni (rituximab-arrx) ING-CC-0094 J9304 Pemfexy (permetrexed) ING-CC-0167 J3590, J9999, C9399 Riabni (rituximab-arrx) ING-CC-0186 J3490, J3590, J9999 Margenza (margetuximab-cmkb) ING-CC-0187 J3490, J3590, J9999 Breyanzi (lisocabtagene maraleucel) ING-CC-0188 J3490, J3590 Imcivree (setmelanotide) ING-CC-0189 J3490, J3590, C9399 Amondys 45 (casimersen) ING-CC-0190 J3490, J3590, C9399 Nulibry (fosdenopterin)

 * Oncology use is managed by AIM.

Quantity limit updates

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

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0189 J3490. J3590, C9399 Amondys 45 ING-CC-0190 J3490, J3590, C9399 Nulibry

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