MP/CG Update/Notice - May 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.  

May 1, 2020

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

Dear Provider:

Anthem Blue Cross is pleased to provide you with our new and updated Clinical Criteria. Please refer to the Clinical Criteria for coding, language, and rationale updates and changes that are not summarized below.

Prior authorization updates

Effective for dates of service on and after August 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Clinical Criteria is located at https://www11.anthem.com/pharmacyinformation/clinicalcriteria.html.

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

Anthem Blue Cross’ (Anthem) 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 Specialty Health® (AIM), a separate company and are in italics.

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0156 C9399, J3490, J3590 Reblozyl
ING-CC-0157 C9399, J9309 Padcev ING-CC-0158 C9399, J3490, J3590, J9999 Enhertu ING-CC-0159 J3490, J3590 Scenesse ING-CC-0155 J0207 Ethyol ING-CC-0160 J3490, J3590 Vyepti ING-CC-0002 C9399, J3590 Ziextenzo ING-CC-0062 J3590 Avsola ING-CC-0062 C9399, J3590 Abrilada ING-CC-0065 J7192 Esperoct

• 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.  

Step therapy updates
Effective for dates of service on and after August 1, 2020, the following specialty pharmacy code from current Clinical Criteria will be included in our existing specialty pharmacy medical step therapy review process. Avsola will be added as a non-preferred agent to Clinical Criteria ING-CC-0062. Step therapy criteria is located at https://www11.anthem.com/provider/noapplication/f0/s0/t0/pw_g350513.pdf Prior authorization clinical review of these specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team.

Clinical Criteria Status Drug(s) HCPCS Code(s) ING-CC-0062 Non-preferred Avsola J3590 Site of care updates
Effective for dates of service on and after August 1, 2020, the following specialty pharmacy codes from current Clinical Criteria will be included in our existing prior authorization site of care review process.

The site of care drug list is located at https://www11.anthem.com/provider/noapplication/f0/s0/t0/pw_g369981.pdf.

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0082 J0222 Onpattro ING-CC-0043 J0517 Fasenra
ING-CC-0049 J1301 Radicava ING-CC-0041 J1303 Ultomiris
ING-CC-0003 J1599 Asceniv
ING-CC-0047 J1746 Trogarzo ING-CC-0050 J3245 Ilumya ING-CC-0013 J3397 Mepsevii ING-CC-0002 Q5110 Nivestym
ING-CC-0002 Q5111 Udenyca

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