MP/CG Update/Notice - August 2020 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.

571-0820-DM-CA 580-0820-DM-CA 581-0820-DM-CA

August 1, 2020

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

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with the following updates. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

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

Specialty Pharmacy updates

Quantity limit updates

Effective for dates of service on and after November 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization quantity limit review process.

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

Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications is managed by AIM and is shown in italics in the table below.

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0044 J1428 Exondys 51 ING-CC-0058* J2354 Bynfezia ING-CC-0072 J0179 Beovu ING-CC-0075 Q5119 Ruxience ING-CC-0152 J1429 Vyondys 53 ING-CC-0153 C9053 Adakveo

• Non-oncology use is managed by the Anthem medical specialty drug review team. Oncology use is managed by AIM.

  Clinical criteria update effective November 1, 2020

  • ING-CC-0003 Immunoglobulins: Updated medical necessity criteria for myasthenia gravis to include specific drug failures and chronic inflammatory demyelinating polyneuropathy to include requirements regarding disease duration, specific electrodiagnostic criterion, and objective measures for continuation.

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.

571-0820-DM-CA 580-0820-DM-CA 581-0820-DM-CA

Correction to prior authorization update on clinical criteria ING-CC-0157: The HCPCS codes available for Padcev at the time of the May 1, 2020 letter were C9399, J3490 and J9999, not C9399 and J9309 as erroneously stated.

Voluntary Site of Care outreach for Oncology Checkpoint Inhibitors beginning August 1, 2020

Anthem is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

Effective with dates of service on or after August 1, 2020, members with commercial plans covered by Anthem will be contacted to voluntarily elect to have services redirected to home infusion site of care from hospital outpatient site of care for certain immuno-oncology drugs (Bavencio [avelumab], Imfinzi [durvalumab], Keytruda [pembrolizumab], Opdivo [nivolumab], Tecentriq [atezolizumab], and Yervoy [ipilimumab]). Reviews for these oncology drugs will continue to be administered by AIM.

The voluntary site of care redirection only applies to these specific drugs administered in an outpatient hospital setting. This does not apply to requests for these specific drugs when administered in a non-hospital setting or as part of an inpatient stay. The redirection also does not apply when Anthem is the secondary payer.

Please note, these reviews do not apply to the following plans: HMO, BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans.

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 back of the member’s ID card.
Note: In some plans “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use “site of care.”

Expansion of AIM Musculoskeletal Program effective November 1, 2020

Effective November 1, 2020, the AIM Musculoskeletal Program will be expanded to include medical necessity reviews for certain elective surgeries of the small joints for Anthem members. AIM will perform the expanded musculoskeletal program and will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (level of care review). The clinical guidelines adopted by Anthem and used by AIM to review for medical necessity and level of care are located at https://aimspecialtyhealth.com/guidelines/185/index.html.

AIM will begin accepting prior authorization requests on October 26, 2020, for dates of service on and after November 1,

2020. To determine if prior authorization is required, please call the prior authorization number located on the back of the member’s ID card.

      Pre-service review requirements For surgeries scheduled to begin on or after November 1, 2020, all providers must contact AIM to obtain prior authorization for the following non-emergency modalities:

      Small joint replacement (including all associated revision surgeries) • Total joint replacement of ankle
      • Correction of Hallux Valgus • Hammertoe repair

      Surgeries performed as part of an inpatient admission are included.

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.

571-0820-DM-CA 580-0820-DM-CA 581-0820-DM-CA

Providers should continue to submit prior authorization requests to AIM using one of the following ways:
• Access AIM’s 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: 877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.

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 and upcoming guidelines, helpful information and tools such as order entry checklists and FAQs at http://www.aimspecialtyhealth.com/ClinicalGuidelines.html.

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