This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).

 

HEDIS medical record submission made easier with our remote EMR access service

 

Let us take on the responsibility to retrieve medical records for the annual HEDIS^® hybrid project by signing up for the remote electronic medical record (EMR) access service offered Anthem.

 

We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.

 

We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:

• We only access medical records of members pulled into the HEDIS sample using specific demographic data.
• We only retrieve the medical records that have claims evidence related to the HEDIS measures.
• We access the least amount of information needed for use, disclosure, or for the specific medical records request.
• We only save to file and do not physically print any PHI.

 

Getting started with remote EMR access

Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.

 

FAQ

How does Anthem retrieve your medical records?

We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.

 

Is printing access necessary?

Yes. The NCQA audit requires print-to-file access.

 

Is this process secure?

Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.

           

Why does Anthem need full access to the entire medical record?

There are several reasons we need to look at the entire medical record of a member:

• HEDIS measures can include up to a 10-year look back at a member’s information.
• Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
• Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.

 

What information do I need to submit to use the remote EMR access service?

Complete the registration form that requests the following information:

• Practice/facility demographic information (for example, address, NPI, TIN, etc.)
• EMR system information (for example, type of EMR system, required access forms, access type, etc.)
• List of current providers/locations or a website for accessing this list

 

Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

MULTI-BCBS-CRCM-004119-22-CPN2931

We’re phasing in clear, concise, and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line was denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.

 

Continuing to improve

The new denial descriptions will be phased in over the next few months. Based on your feedback, we’re starting with those claims or claim lines that have caused the most confusion. If new denial reasons are added, the descriptions will be expanded as well.

 

Accessing claim statuses

The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.

 

If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

CTBCBS-CM-10775-22

When submitting claims through the Electronic Data Interchange (EDI), a PWK segment indicator tells us you will be submitting supporting documentation for the claim and ensures the documents are attached correctly. The supporting documents are then sent through the Availity Essentials* Attachments Dashboard.

 

In November, the Attachments Dashboard will have a new look for Anthem Blue Cross and Blue Shield claims

The sooner we receive your claim attachments, the faster your claim can be processed for payment. To meet this expectation, the Attachments Dashboard will begin a seven calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.

 

If you are unable to meet the seven calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.

 

To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow, using this link.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

CTBCBS-CM-10775-22

Submitting Anthem Blue Cross and Blue Shield claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.

 

Add multiple claims to one dispute submission

You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.

 

Access acknowledgement, update, and decision letters digitally, too

Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the CI-COMM case number.

 

Availity Essentials appeals training

For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

CTBCBS-CM-10775-22

New learnings added to the Provider Learning Hub.

 

Remittance Inquiry App: How to view, print, and save remittance advice

If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.

 

Attachments: How to setup the Medical Attachment role

To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.

 

Claim Submission: How to submit a claim using direct data entry

For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.

 

Get started today  

Access the Provider Learning Hub today using this link or from anthem.com under Important Announcements on the home page. 

• All courses and webcasts are available 24/7 for your convenience.
• Use filtering options to quickly find courses and job aids.
• Use the Favorites folder to save items for easy access later.
• Once registered, no further registration is required.
  • On future visits, your preferences are populated eliminating the need for any additional logon information.

 

Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

CTBCBS-CM-10775-22

The following new and revised medical policies and clinical guidelines were endorsed at the August 11, 2022, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies and clinical guidelines, are available at anthem.com/provider > select state > scroll down and select See Policies and Guidelines.

 

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. 

 

Medical policy updates

 

Revised medical policies effective August 18, 2022

The following policies were revised to expand medical necessity indications or criteria:

• MED.00129 Gene Therapy for Spinal Muscular Atrophy
• SURG.00121 Transcatheter Heart Valve Procedures

 

New medical policy effective August 22, 2022

The following policy is new:

• MED.00140 Gene Therapy for Beta Thalassemia

 

Revised medical policy effective September 7, 2022

The following policy was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:

• MED.00129 Gene Therapy for Spinal Muscular Atrophy

 

New medical policy effective September 28, 2022

The following policy is new:

• MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy

 

Revised medical policies effective September 28, 2022

The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:

• LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
• SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention

 

Revised medical policies effective September 28, 2022

The following policies were updated with new CPT®/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
• GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
• GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD)
• GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
• GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• LAB.00015 Detection of Circulating Tumor Cells
• LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease
• MED.00098 Hyperoxemic Reperfusion Therapy
• RAD.00038 Use of 3-D, 4-D, or 5-D Ultrasound in Maternity Care
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00120 Internal Rib Fixation Systems
• TRANS.00038 Thymus Tissue Transplantation

 

Archived medical policy effective October 5, 2022

The following policy has been archived:

• GENE.00034 SensiGene® Fetal RhD Genotyping Test

 

Revised medical policies effective October 5, 2022

The following policies were revised to expand medical necessity indications or criteria:

• MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
• SURG.00119 Endobronchial Valve Devices
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Revised medical policies effective October 5, 2022

The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:

• ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
• DME.00025 Self-Operated Spinal Unloading Devices
• DME.00041 Ultrasonic Diathermy Devices
• DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
• GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site
• GENE.00020 Gene Expression Profile Tests for Multiple Myeloma
• GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies
• GENE.00058 TruGraf Blood Gene Expression Test for Transplant Monitoring
• LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
• LAB.00011 Selected Protein Biomarker Algorithmic Assays
• LAB.00028 Serum Biomarker Tests for Multiple Sclerosis
• LAB.00029 Rupture of Membranes Testing in Pregnancy
• LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
• LAB.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
• LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia
• LAB.00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy
• MED.00055 Wearable Cardioverter Defibrillators
• MED.00082 Quantitative Sensory Testing
• MED.00089 Quantitative Muscle Testing Devices
• MED.00096 Low-Frequency Ultrasound Therapy for Wound Management
• MED.00103 Automated Evacuation of Meibomian Gland
• MED.00134 Non-invasive Heart Failure and Arrhythmia Management and Monitoring System.
• OR-PR.00007 Microprocessor Controlled Knee-Ankle-Foot Orthosis
• RAD.00057 Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
• RAD.00061 PET/MRI
• RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
• SURG.00008 Mechanized Spinal Distraction Therapy
• SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• SURG.00077 Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
• SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
• SURG.00088 Coblation® Therapies for Musculoskeletal Conditions
• SURG.00092 Implanted Devices for Spinal Stenosis
• SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
• SURG.00107 Prostate Saturation Biopsy
• SURG.00114 Facet Joint Allograft Implants for Facet Disease
• SURG.00128 Implantable Left Atrial Hemodynamic Monitor
• SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
• SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves
• SURG.00144 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
• SURG.00153 Cardiac Contractility Modulation Therapy
• SURG.00156 Implanted Artificial Iris Devices
• SURG.00157 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

 

Archived medical policy effective November 6, 2022

The following policy has been archived and has been replaced by AIM guidelines:

• SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy

 

New medical policies effective February 1, 2023

The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• DME.00049 External Upper Limb Stimulation for the Treatment of Tremors
• DME.00050 Remote Devices for Intermittent Monitoring of Intraocular Pressure
• LAB.00049 Artificial Intelligence-Based Software for Prostate Cancer Detection
• MED.00141 High-volume Colonic Irrigation
• TRANS.00040 Hand Transplantation

 

Revised medical policies effective February 1, 2023

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• DME.00044 Robotic Arm Assistive Devices
• SURG.00079 Nasal Valve Repair

 

Clinical guideline updates

 

Revised clinical guideline effective August 24, 2022

The following adopted guideline was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:

• CG-MED-68 Therapeutic Apheresis

 

Revised clinical guidelines effective September 28, 2022

The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:

• CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
• CG-MED-68 Therapeutic Apheresis
• CG-SURG-97 Cardioverter Defibrillators

 

Unadopted clinical guideline effective October 1, 2022

The criteria in the following guideline will no longer be applied:

• CG-SURG-96 Intraocular Telescope

 

Revised clinical guideline effective October 5, 2022

The following adopted guideline was revised to expand medical necessity indications or criteria:

• CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment

 

Revised clinical guideline effective October 5, 2022

The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:

• CG-BEH-02 Adaptive Behavioral Treatment
• CG-DME-10 Durable Medical Equipment
• CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
• CG-DME-44 Electric Tumor Treatment Field (TTF)
• CG-MED-55 Site of Care: Advanced Radiologic Imaging
• CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
• CG-MED-65 Manipulation Under Anesthesia
• CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
• CG-MED-69 Inhaled Nitric Oxide
• CG-MED-83 Site of Care: Specialty Pharmaceuticals
• CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 Private Duty Nursing in the Home Setting
• CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
• CG-SURG-52 Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services
• CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
• CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
• CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

 

Revised clinical guideline effective February 1, 2023

The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CG-DME-31 Powered Wheeled Mobility Devices
• CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
• CG-GENE-13 Genetic Testing for Inherited Diseases

 

CTBCBS-CM-009375-22

This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Connecticut.

 

Effective November 6, 2022, Anthem will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health_®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal_SM directly at https://providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access AIM via Availity* at availity.com.

 

For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com.

 

Additionally, you may access and download a copy of the current and upcoming guidelines here.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

CTBCBS-CRCM-006034-22-CPN5953

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_®* (AIM), 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.

 

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.

 

Prior authorization updates

Effective for dates of service on and after February 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 to view the complete information for these prior authorization updates.

 

Clinical Criteria	Drug	HCPCS or CPT® code(s)
ING-CC-0002*	Fylnetra (pegfilgrastim-pbbk)	J3590
ING-CC-0002*	Rolvedon (eflapegrastim-xnst)	C9399, J3490, J3590
ING-CC-0002*	Stimufend (pegfilgrastim-fpgk)	C9399, J3490, J3590
ING-CC-0072	Cimerli (ranibizumab-cqrn)	J3590
ING-CC-0220	Xenpozyme (olipudase alfa)	C9399, J3490, J3590
ING-CC-0221	Spevigo (spesolimab-sbzo)	C9399, J3490, J3590

* Oncology use is managed by AIM.

 

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

 

Site of care updates

Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.

 

Access our Clinical Criteria to view the complete information for these site of care updates.

 

Clinical Criteria	Drug	HCPCS or CPT code(s)
ING-CC-0065	Advate (factor viii (antihemophilic factor, recombinant))	J7192
ING-CC-0065	Adynovate (factor vii)	J7207
ING-CC-0065	Afstyla (antihemophilic factor (recombinant) single chain))	J7210
ING-CC-0065	Alphanate (antihemophilic factor viii)	J7186
ING-CC-0065	Eloctate (recombinant antihemophilic factor)	J7205
ING-CC-0065	Esperoct (factor viii recombinant, glycopegylated)	J7204
ING-CC-0065	factor viii, anti-hemophilic factor (porcine)	J7191
ING-CC-0065	Hemlibra (emicizumab-kxwh)	J7170
ING-CC-0065	Hemofil M ((factor viii) human plasma-derived)	J7190
ING-CC-0065	Humate-P (antihemophilic factor viii)	J7187
ING-CC-0065	Jivi (factor viii, recombinant, pegylated-aucl)	J7208
ING-CC-0065	Koate DVI ((factor viii) human plasma-derived)	J7190
ING-CC-0065	Kogenate-FS (factor viii (antihemophilic factor, recombinant))	J7192
ING-CC-0065	Kovaltry (factor viii (antihemophilic factor, recombinant))	J7211
ING-CC-0065	Novoeight (factor viii (antihemophilic factor, recombinant))	J7182
ING-CC-0065	Nuwiq (factor viii (antihemophilic factor, recombinant))	J7209
ING-CC-0065	Obizur (antihemophilic factor viii (recombinant))	J7188
ING-CC-0065	Recombinate (factor viii (antihemophilic factor, recombinant))	J7192
ING-CC-0065	Vonvendi (von willebrand factor)	J7179
ING-CC-0065	Wilate (antihemophilic factor viii)	J7183
ING-CC-0065	Xyntha (factor viii (antihemophilic factor, recombinant))	J7185
ING-CC-0065	Xyntha Solofus (factor viii (antihemophilic factor, recombinant))	J7185
ING-CC-0148	AlphaNine SD (coagulation factor ix (human))	J7193
ING-CC-0148	Alprolix (recombinant coagulation factor ix)	J7201
ING-CC-0148	Benefix (factor ix recombinant)	J7195
ING-CC-0148	Idelvion (factor ix)	J7202
ING-CC-0148	Ixinity (factor ix)	J7195
ING-CC-0148	Mononine (coagulation factor ix (human))	J7193
ING-CC-0148	Profilnine SD (factor ix complex human)	J7194
ING-CC-0148	Rebinyn (glycopegylated)	J7203
ING-CC-0148	Rixubis (factor ix recombinant)	J7200
ING-CC-0149	Coagadex (factor x)	J7175
ING-CC-0149	Corifact (factor xiii concentrate (human))	J7180
ING-CC-0149	Feiba (anti-inhibitor coagulant complex)	J7198
ING-CC-0149	Fibryga (human fibrinogen)	J7177
ING-CC-0149	NovoSeven RT (factor viia recombinant)	J7189
ING-CC-0149	RiaSTAP (fibrinogen concentrate)	J7178
ING-CC-0149	Sevenfact (factor vlla recombinant)	J7212
ING-CC-0149	Tretten (coagulation factor xiii a-subunit (recombinant))	J7181

 

Step therapy updates

Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. 

 

Clinical Criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro, and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long‑acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.

 

Access our Clinical Criteria to view the complete information for these step therapy updates.

 

Clinical Criteria	Status	Drug	HCPCS or CPT code(s)
ING-CC-0002*	Non-preferred	Fylnetra	J3590
ING-CC-0002*	Non-preferred	Rolvedon	C9399, J3490, J3590
ING-CC-0002*	Non-preferred	Stimufend	C9399, J3490, J3590
ING-CC-0002	Preferred	Neulasta	J2506
ING-CC-0002	Preferred	Neulasta OnPro	J2506
ING-CC-0002	Preferred	Udenyca	Q5111
ING-CC-0002	Non-preferred	Fulphila	Q5108
ING-CC-0002	Non-preferred	Nyvepria	Q5122
ING-CC-0002	Non-preferred	Ziextenzo	Q5120

*Oncology use is managed by AIM

 

This is a courtesy notice that there is a non-material change in the Clinical Criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).

 

Quantity limit updates

Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

 

Access our Clinical Criteria to view the complete information for these quantity limit updates.

 

Clinical Criteria	Drug	HCPCS or CPT code(s)
ING-CC-0017	Xiaflex (collagenase clostridium histolyticum)	J0775
ING-CC-0072	Cimerli (ranibizumab-cqrn)	J3590
ING-CC-0182	Feraheme (ferumoxytol)	Q0138
ING-CC-0182	Ferrlecit (ferric gluconate)	J2916
ING-CC-0182	Infed (iron dextran)	J1750
ING-CC-0182	Injectafer (ferric injection)	J1439
ING-CC-0182	Monoferric (ferric derisomaltose)	J1437
ING-CC-0182	Venofer (iron sucrose)	J1756
ING-CC-0220	Xenpozyme (olipudase alfa)	C9399, J3490, J3590
ING-CC-0221	Spevigo (spesolimab-sbzo)	C9399, J3490, J3590

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

MULTI-BCBS-CM-10243-22