MP/CG Update/Notice - August 2021 Form

P.O. Box 4330 Woodland Hills, CA 91365 1 676-0721-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.

August 1, 2021

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

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.

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, or FEP. For more information, please contact the phone number of the back of the member’s ID card.

Specialty Referrals for Participating HMO Medical Groups withdrawn

We previously informed our Participating HMO Medical Groups on April 1, 2021, and July 1, 2021, of a requirement to submit all specialty out-of-network referral information to Anthem in order to comply with the Department of Managed Health Care and the Knox-Keene Act. This requirement has now been withdrawn. We apologize for any inconvenience.

Update to Medical Policy converted to Clinical Guideline

Our July 1, 2021 provider letter included notification of the conversion of SURG.00127 (Sacroiliac Joint Fusion) to CG-SURG-111 (Open Sacroiliac Joint Fusion) effective September 12, 2021. Please note that the effective date of this conversion has been moved to July 30, 2021. As a reminder, elective, non-emergent, percutaneous/ minimally invasive Sacroiliac Joint Fusion is reviewed by AIM for Musculoskeletal program-eligible members.

Updated Medical Policy requirements effective November 1, 2021

• GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
This document addresses whole genome sequencing, whole exome sequencing, and gene panel testing.
o Prior authorization will be required for non-AIM eligible members effective November 1, 2021

• MED.00127 Chelation Therapy: This document addresses the use of chelation therapy.
o Prior authorization will be required effective November 1, 2021

2 676-0721-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.

Specialty Pharmacy prior authorization updates

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy drugs from 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.

Clinical Criteria 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.

• Oncology use is managed by AIM.

  Specialty Pharmacy quantity limit updates

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

  Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0199 C9399, J3490. J3590 Empaveli (pegcetacoplan)

  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 Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0196 J3490, J3590, J9999 Zynlonta (loncastuximab tesirine-lpyl) ING-CC-0197 J3490, J3590, J9999 Jemperli (dostarlimab) ING-CC-0199 C9399, J3490, J3590 Empaveli (pegcetacoplan)