MP/CG Update/Notice - September 2023 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. CABC-CM-037968-23

August 2023

September 1, 2023

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with our new Medical Policy. Please refer to the specific policy for coding, language and rationale not summarized below.

NEW Medical Policy

• MED.00144 Gene Therapy for Duchenne Muscular Dystrophy: This document addresses gene therapy for Duchenne muscular dystrophy (DMD), a rare and serious genetic disease affecting muscle strength and movement. o Considered Investigational and Not Medically Necessary o Prior authorization required effective December 1, 2023

Revised Medical Policy effective July 10, 2023

• MED.00135 Gene Therapy for Hemophilia: This document addresses gene therapy for hemophilia, a congenital medical condition in which the blood does not clot normally due to lack of sufficient blood-clotting proteins known as clotting factors. o Revised Medically Necessary statement on etranacogene dezaparvovec-drlb
o Added Medically Necessary statement on valoctocogene roxaparvovec-rvox o Revised first Investigational and Not Medically Necessary statement and deleted second Investigational and Not Medically Necessary statement

Specialty pharmacy updates

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Anthem’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.,* a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

By including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

Prior authorization updates

Effective for dates of service on and after [December 1, 2023], the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria at anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these updates.

Clinical Criteria Drug HCPCS or CPT code(s) CC-0062 Yuflyma (adalimumab-aaty) J3490, J3590 CC-0238 Hydroxprogesterone caproate J1729 CC-0241 Elfabrio (pegunigalsidase alfa-iwxj) J3490, J3590 CC-0242 Epkinly (epcoritamab-bysp) C9399, J3490, J3590, J9999 CC-0243 Vyjuvek (beremagene geperpavec) J3490, J3590

• Oncology use is managed by Carelon Medical Benefits Management.

  Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Effective for dates of service on and after [December 1, 2023], the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

Clinical Criteria Drug HCPCS or CPT code(s) CC-0062 Yuflyma (adalimumab-aaty) J3490, J3590 CC-0228 Leqembi (lecanemab) J0174 CC-0241 Elfabrio (pegunigalsidase alfa-iwxj) J3490, J3590 CC-0243 Vyjuvek (beremagene geperpavec) J3490, J3590

Carelon Medical Benefits Management, Inc. advanced imaging — imaging of the brain CPT code list update

Effective for dates of service on and after December 1, 2023, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

Updates to Carelon Medical Benefits Management, Inc. (Carelon) 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 Carelon. They do not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program® (FEP®). For more information, please contact the phone number of the back of the member ID card.

CPT code Description 0042T Cerebral Perfusion Analysis Using Computed Tomography with Contrast Administration, Including Post-Processing of Parametric Maps with Determination of Cerebral Blood Flow, Cerebral Blood Volume, and Mean Transit Time

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon in one of several ways:
• Access Carelon’s ProviderPortalSM directly at providerportal.com:
o Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. • Access Carelon via the Availity Essentials* website at availity.com.

If you have any questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines https://guidelines.carelonmedicalbenefitsmanagement.com.

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the Anthem Blue Cross Web site at http://www.anthem.com/ca and then selecting “For Providers”, then selecting “Policies, Guidelines & Manuals” under the Provider Resources column, select “Change State” and choose California, 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.

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