Effective December 1, 2018, prior authorization (PA) requirements will change for Part B injectable/infusible drugs Moxetumomab Pasudotox, Cemiplimab and Fulphila (pegfilgrastim-jmbd) to be covered by Anthem Blue Cross for Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

  • Moxetumomab pasudotox — for treatment of relapsed or refractory hairy cell leukemia in patients who have received at least two prior lines of therapy (J3590, J9999)
  • Cemiplimab — PD-1 inhibitor for the treatment of patients with metastatic cutaneous squamous cell carcinoma (CSCC) or patients with locally advanced CSCC who are not eligible for surgery (J3590, J9999)
  • Fulphila (pegfilgrastim-jmbd) — a biosimilar to Neulasta approved for febrile neutropenia in patients with chemotherapy in certain types of cancer (J3490, J3590)

 

Please note, one or more of the drugs noted above are currently billed under the not otherwise classified (NOC) HCPCS J-codes J3490, J3590 and J9999. Since these codes include all drugs that are NOC, if the authorization is denied for medical necessity, the plan’s denial will be for the drug and not the HCPCS code.

 

To request PA, you may use one of the following methods:

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call the Customer Care Center at 1-855-817-5786 for PA requirements.



Featured In:
October 2018 Anthem Blue Cross Provider Newsletter - California