MP/CG Update/Notice - February 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.

979-0221-DM-CA

February 1, 2021

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

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with an updated Medical Policy and Clinical Criteria. 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.

UPDATED Medical Policy effective May 1, 2021

• SURG.00121 Transcatheter Heart Valve Procedures: This document addresses the transcatheter (percutaneous or catheter-based) approach for aortic or pulmonary heart valve replacement, transcatheter mitral valve repair using leaflet repair or percutaneous annuloplasty, and transcatheter tricuspid valve repair or replacement. o Prior authorization required effective May 1, 2021

Important Update for Psychiatric Mental Health Nurse Practitioners

Transcranial Magnetic Stimulation (TMS) for the treatment of Major Depressive Disorder will be added to our Psychiatric Mental Health Nurse Practitioner (NP) fee schedules. We anticipate the effective date to be on or about May 1, 2021 for Psychiatric Mental Health NPs that are fully credentialed, trained in the application of TMS, and with Standardized Procedures agreement signed by a licensed California psychiatrist.

Prior authorization updates for specialty pharmacy

Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents 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.

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

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 are shown in italics in the tables below.

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0183 J3590 Sogroya ING-CC-0001 J0886 Injection, epoetin alfa (Procrit/Epogen) ING-CC-0019 J3489 Reclast, Zometa *Oncology use is managed by AIM.

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.

979-0221-DM-CA

Quantity Limit Updates

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

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0019 J3489 Reclast, Zometa Oncology use is managed by AIM.

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