 Provider News MaineApril 1, 2025 April 2025 Provider Newsletter Contents Policy Updates | Anthem Blue Cross and Blue Shield | Medicare Advantage / AMH Health, LLC | Medicare Advantage | February 27, 2025 Clinical Criteria updates
On January 1, 2025, we launched Health Perks, a new incentive program that rewards members for completing select healthcare activities. This program is available for a select number of our plans. Please confirm member eligibility before promoting the program benefits. For more information or to verify eligibility, benefits, or account details, call the number located on the back of the member’s ID card. Limited health plan eligibilityThese are the Health Perks plans eligible for rewards. Plan number | State | Plan | H4346-014-000 | CO | Anthem Dual Advantage (HMO D-SNP) | H2836-006-000 | CT | Anthem Full Dual Advantage (PPO D-SNP) | H5854-008-000 | CT | Anthem Full Dual Advantage 2 (HMO D-SNP) | H5854-013-000 | CT | Anthem Full Dual Advantage Select (HMO D-SNP) | H4036-032-000 | GA | Anthem Full Dual Advantage (PPO D-SNP) | H4036-039-000 | GA | Anthem Dual Advantage (PPO D-SNP) | H5422-018-000 | GA | Anthem Dual Advantage (HMO D-SNP) | H5422-019-000 | GA | Anthem Full Dual Advantage (HMO D-SNP) | H3447-020-000 | IN | Anthem Full Dual Advantage (HMO D-SNP) | H3447-046-000 | IN | Anthem Dual Advantage (HMO D-SNP) | H3447-048-000 | IN | Anthem Full Dual Advantage Aligned (HMO D-SNP) | H3447-055-000 | IN | Anthem Full Dual Advantage Aligned NFLOC (HMO D-SNP) | H9525-007-000 | KY | Anthem Full Dual Advantage (HMO D-SNP) | H9525-016-000 | KY | Anthem Dual Advantage (HMO D-SNP) | H9525-019-000 | KY | Anthem Full Dual Advantage 2 (HMO D-SNP) | H3447-018-000 | MO | Anthem Full Dual Advantage (HMO D-SNP) | H3447-047-000 | MO | Anthem Dual Advantage (HMO D-SNP) | H3447-053-000 | MO | Anthem Full Dual Advantage 2 (HMO D-SNP) | H4346-025-000 | NV | Anthem Full Dual Advantage (HMO D-SNP) | H4346-026-000 | NV | Anthem I Carelon Full Dual Advantage (HMO D-SNP) | H8432-041-000 | NY | Anthem HealthPlus Full Dual Advantage LTSS (HMO D-SNP) | H8432-042-000 | NY | Anthem HealthPlus Full Dual Advantage (HMO D-SNP) | H3655-033-000 | OH | Anthem Full Dual Advantage (HMO D-SNP) | H3655-048-000 | OH | Anthem Dual Advantage (HMO D-SNP) | H3655-049-000 | OH | Anthem Full Dual Advantage 2 (HMO D-SNP) | H2441-001-000 | VA | Wellpoint Dual Advantage 2 (HMO D-SNP) | H9525-003-000 | WI | Anthem Full Dual Advantage (HMO D-SNP) | H9525-012-000 | WI | Anthem Dual Advantage (HMO D-SNP) | H9525-018-000 | WI | Anthem Full Dual Advantage 2 (HMO D-SNP) |
Health Perks rewardsThese are the eligible healthcare activities, member rewards, and claim codes. Healthcare activity | Reward amount | Eligible claim codes | Annual wellness visit/annual physical | $30 | 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, G0438, G0439, G0463, G0468, Z00.00, Z00.01, Z00.8 | Breast cancer screening | $20 | 77061, 77062, 77063, 77065, 77066, 77067 | Colorectal screening | $30 | 4522, 4523, 4525, 4542, 4543, 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398, G0105, G0121, 74261, 74262, 74263, 4524, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 45347, 45349, 45350, G0104 | Fecal occult blood test | $10 | 82270, 82274, G0328, 81528 | Bone density screening | $10 | 8898, 76977, 77078, 77080, 77081, 77085, 77086, BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00ZZ1, BQ01ZZ1, BQ03ZZ1, BQ04ZZ1, BR00ZZ1, BR07ZZ1, BR09ZZ1, BR0GZZ1, J0897, J1740, J3489, J3110, J3111 | Flu vaccine | $10 | 90630, 90653, 90654, 90656, 90658, 90661, 90662, 90673, 90674, 90682, 90686, 90688, 90689, 90694, 90756, 90660, 90672 |
Claim coverage notes:- For colonoscopies, annual wellness visits, and breast cancer screenings, members will not have out‑of‑pocket costs or a copayment when performed by an in‑network provider:
- Note: A cost share may be applicable for any additional services or tests conducted during the visit for each service listed in the healthcare activity chart above.
- For bone density screenings, Medicare Part B (for doctor visits, outpatient procedures, preventive services, home health services, and DME) covers this test once every 24 months (or more often if medically necessary) when at least one of the following conditions is met:
- Their care provider has determined they are estrogen‑deficient and at risk for osteoporosis based on their medical history and other findings.
- Their X‑rays show possible osteoporosis, osteopenia, or vertebral fractures.
- They are taking prednisone or steroid‑type drugs or are planning to begin this treatment.
- They have been diagnosed with primary hyperparathyroidism.
- They are being monitored to see if their osteoporosis drug therapy is working.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-075375-24-CPN75369, MULTI-BCBS-CR-078045-25 Administrative | Anthem Blue Cross and Blue Shield | Commercial | April 1, 2025 Notice of material change/amendment to contract Notices of material changes/amendments to contract — April 2025Notices of material changes/amendments to contract may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements. In this issue, please reference the following articles: - Specialty pharmacy updates — April 2025
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MEBCBS-CM-080591-25 At a glance:- The Provider Enrollment and Network Management tool on Availity Essentials offers streamlined data submission and real‑time status tracking.
- Administrators can manage access via Availity Essentials, enabling roles for provider enrollment and network management features.
- Practice profile changes are facilitated electronically through the Provider Data Management application on Availity Essentials.
Starting April 24, 2025, we will add additional provider specialties and network management functionality to our Provider Enrollment and Network Management application available in Payer Spaces after logging in to Availity Essentials at https://Availity.com. Features of the Provider Enrollment and Network Management application include:- Ability to enroll as a new care provider.
- Ability to request to join our network. After review, a contract can be sent back to you digitally for an electronic signature. This eliminates the need for paper applications or paper contracts.
- A dashboard for the real‑time status of the submitted applications.
- Streamlined complete data submission.
- Additional options to manage your network.
How to use the online Provider Enrollment and Network Management applicationThe online application will guide you throughout the provider enrollment and network management process, providing status updates using My Dashboard within the Provider Enrollment and Network Management application. As a result, you know where you are in the process without having to call or email for a status. Note: For any changes to your practice profile and demographics, use the Provider Data Management (PDM) application on Availity Essentials, which allows you to electronically submit any changes to your practice profile and demographics. Availity Essentials administrators and assistant administrators can access it by going to Availity Essentials > My Providers > Provider Data Management. Accessing the Provider Enrollment application:- Log on to Availity Essentials and select Payer Spaces > Anthem > Applications > Provider Enrollment and Network Management to begin the enrollment process.
- If your organization is not currently registered for Availity Essentials, the person in your organization designated as the Availity Essentials administrator should go to https://Availity.com and select Register.
- For organizations already using Availity Essentials, your organization's Availity Essentials administrator should go to My Account Dashboard from the Availity Essentials home page to register new users and update or unlock accounts for existing users. Staff who need access to the Provider Enrollment tool need to be granted the role of Provider Enrollment.
Availity Essentials administrators and User administrators will automatically be granted access to Provider Enrollment. - If you are using Availity Essentials today and need access to provider enrollment, work with your organization’s administrator to update your Availity Essentials role. To determine who your administrator is, you can go to My Account Dashboard > My Administrators.
Contact usAvaility Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.
For additional support, visit the Contact Us section of our provider website for the appropriate contact. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MEBCBS-CRCM-075208-24-CPN74723, MEBCBS-CRCM-080084-25-CPN79727 When working with diabetic patients, it is essential to consider various factors to help them maintain their health and well‑being. Led by Dr. Daniel Brunner and Dr. Ann Marie Parker, this webinar will focus on adapting standardized guidelines for diabetes treatment and finding ways to overcome potential obstacles. Apply the knowledge you gain from this webinar to improve your organization’s overall quality. Key measures to be highlighted: - Diabetes Care — Blood Sugar Controlled
- Diabetes Care — Eye Exam
- Medication Adherence for Diabetes Medications
- Statins Use in Persons with Diabetes (SUPD)
- Kidney Evaluation for Patients with Diabetes (KED)
| Tuesday, April 8, 2025Noon Eastern time |
This session is approved for one American Academy of Family Physicians credit.
Register today!* * Registration page opens best in the Google Chrome browser. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MEBCBS-CRCM-080259-25-CPN79397 We’re excited to introduce two new Payment Integrity trainings available on our Digital Solutions Learning Hub: - Payment Integrity: Emergency Dept Evaluation and Management Services
- Payment Integrity: Outpatient Evaluation and Management Services
With an initial focus on these two key educational initiatives, our purpose is to amplify your billing and coding accuracy. More trainings will be announced throughout the year. Discover what our Digital Solutions Learning Hub has to offer. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MEBCBS-CRCM-072248-24-CPN72085, MEBCBS-CRCM-075937-24-CPN75258, MEBCBS-CRCM-077822-25-CPN77515, MEBCBS-CRCM-080172-25-CPN79720 Education & Training | Anthem Blue Cross and Blue Shield | Commercial / Anthem Blue Cross and Blue Shield | Medicare Advantage / AMH Health, LLC | Medicare Advantage | February 28, 2025 Resources to support diverse patients and communitiesOur goal is to create and source materials to help support care providers understand and address the diverse needs of patients while maintaining professionalism, trust, and respect. Health equity means everyone has the opportunity to reach their highest level of health, and barriers must be removed. How do cultural factors influence a person's approach to illness and healthcare?Culture, including behaviors, language, beliefs, and values, shapes an individual's approach to illness. Experiences, education, and spiritual beliefs also play a role. Patients may perceive illness differently than healthcare providers. Recognizing these differences can improve health outcomes while ignoring them can lead to misunderstandings and non‑compliance. How can we address health disparities?Health disparities refer to differences in health outcomes linked to unequal social, economic, and environmental opportunities.1 Achieving health equity and optimal health outcomes involves eliminating barriers related to race, ethnicity, gender, religion, socioeconomic status, disability, and geographic location.2 Addressing these disparities fosters healthier communities, enhances quality of life, and supports economic growth by creating a more productive and resilient population. It is essential to meet people where they are in their health journeys and provide tailored healthcare access to address patients' unique needs, and we are committed to supporting our providers in this effort. Cultural competency resourcesYou can find cultural competency resources available on our provider website: - Cultural Competency and Patient Engagement:
- A training resource to increase cultural and disability competency to help effectively support the health and healthcare needs of all your patients.
- Caring for Diverse Populations Toolkit:
- A comprehensive resource to help providers and office staff increase effective communication by enhancing knowledge of the values, beliefs, and needs of all patients.
To access these resources, go to the provider website > Resources > Training Academy. Our provider manual also has details about available resources and how to access them. Prevalent non‑English languages (based on population data)Like you, we want to effectively serve the needs of diverse patients. We must all be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the top 15 non‑English languages spoken by 5% or 1,000 individuals in the state.3 Prevalent non‑English languages in Maine by 5% or 1000 individuals | French (including Cajun) | Spanish | Amharic, Somali, or other Afro‑Asiatic languages | Chinese (including Mandarin, Cantonese) | Yiddish, Pennsylvania Dutch, or other West Germanic languages | Swahili or other languages of Central, Eastern, and Southern Africa | Portuguese | Arabic | German | Tagalog (including Filipino) | Other Indo‑European languages | Russian | Italian | Vietnamese | Khmer |
Language support servicesWe provide free language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Telephone interpretersDuring business hours, providers can call at to connect to an interpreter on behalf of the member. After business hours, call the 24/7 NurseLine on the back of a member ID card. Face‑to‑face interpretersIf you would like to request an interpreter, including sign language, on behalf of your patient, please call Provider Services. Three business days are required to schedule services, and 24 business hours are required to cancel. TTY and relay servicesFor members with hearing or speech loss, members may call the TTY line on the back of a member ID card or 711. After business hours, they should call the 24/7 NurseLine. Leverage the knowledge, skills, values, strategies, and techniques available to foster a trusted partnership with your patients. Access these resources today to enhance your shared journey in healthcare. Sources
1 Office of Disease Prevention and Health Promotion. (2022, Feb 6). Health Equity in Healthy People 2030. Retrieved from https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health
2 Elevance Health. (2022, Feb 7). What Are Health Disparities? Retrieved from https://elevancehealth.com/our‑approach‑to‑health/health‑equity/what‑are‑health‑disparities
3 American Community Survey, 2024 American Community Survey 1‑Year Estimates, Table B16001, generated July 2024. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Plans offered by AMH Health, LLC., a joint venture between MaineHealth and Anthem Partnership Holding Company, LLC. AMH Health is an independent licensee of the Blue Cross Blue Shield Association. MEBCBS-CRCM-076853-24-CPN75666 Policy Updates | Anthem Blue Cross and Blue Shield | Medicare Advantage / AMH Health, LLC | Medicare Advantage | February 27, 2025 Clinical Criteria updatesSummary: The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
Please share this notice with other members of your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective Date | Clinical Criteria Number | Clinical Criteria Title | New or Revised | March 28, 2025 | CC-0274 | Bizengri (zenocutuzumab-zbco) | New | March 28, 2025 | CC-0275 | Ziihera (zanidatamab-hrii) | New | March 28, 2025 | CC-0276 | Tryngolza (olezarsen) | New | March 28, 2025 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | March 28, 2025 | CC-0185 | Oxlumo (lumasiran) | Revised | March 28, 2025 | CC-0198 | Relizorb (immobilized lipase) cartridge | Revised | March 28, 2025 | CC-0256 | Rivfloza (nedosiran) | Revised | March 28, 2025 | CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised | March 28, 2025 | CC-0063 | Ustekinumab Agents (Stelara, Selarsdi, Imuldosa, Pyzchiva, Otulfi, Wezlana, Yesintek) | Revised | March 28, 2025 | CC-0058 | Bynfezia Pen, Sandostatin, or Sandostatin LAR (Octreotide) / Octreotide Agents | Revised | March 28, 2025 | CC-0130 | Imfinzi (durvalumab) | Revised | March 28, 2025 | CC-0094 | Pemetrexed | Revised | March 28, 2025 | CC-0003 | Immunoglobulins | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Plans offered by AMH Health, LLC., a joint venture between MaineHealth and Anthem Partnership Holding Company, LLC. AMH Health is an independent licensee of the Blue Cross Blue Shield Association. MEBCBS-CR-077231-25-CPN76946 Medical Policy & Clinical Guidelines | Anthem Blue Cross and Blue Shield | Medicare Advantage / AMH Health, LLC | Medicare Advantage | March 11, 2025 Medical Policies and Clinical Utilization Management Guidelines updateThe Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary. Please share this notice with other members of your practice and office staff. To view a guideline, visit the Medical Policy and Clinical UM Guidelines website. Medical PoliciesThe Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect April 12, 2025. Publish date | Medical Policy number | Medical Policy title | New or revised | October 1, 2024 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised | October 1, 2024 | DME.00052 | Brain Computer Interface Rehabilitation Devices | New | October 1, 2024 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions
Previously titled: Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer | Revised | October 1, 2024 | LAB.00051 | Per‑ and Polyfluoroalkyl Substances PFAS Testing | New | October 1, 2024 | MED.00150 | Hepzato Kit™ (melphalan hepatic delivery system) | New | October 1, 2024 | SURG.00032 | Patent Foramen Ovale and Left Atrial Appendage Closure Devices
Previously titled: Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention | Revised | October 1, 2024 | TRANS.00023 | Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias | Revised |
Clinical UM GuidelinesThe MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect April 12, 2025. Publish date | Clinical UM Guideline number | Clinical UM Guideline title | New or revised | October 1, 2024 | CG‑LAB-33 | Carcinoembryonic Antigen Testing | New | October 1, 2024 | CG‑LAB-35 | Cancer Antigen 19‑9 Testing | New | October 1, 2024 | CG‑MED-39 | Bone Mineral Density Testing Measurement | Revised | October 1, 2024 | CG‑SURG-01 | Colonoscopy | Revised | October 1, 2024 | CG‑SURG-122 | Lingual Frenotomy for Ankyloglossia‑Related Feeding Difficulties | New | October 1, 2024 | CG‑SURG-57 | Diagnostic Nasal Endoscopy | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Plans offered by AMH Health, LLC., a joint venture between MaineHealth and Anthem Partnership Holding Company, LLC. AMH Health is an independent licensee of the Blue Cross Blue Shield Association. MEBCBS-CR-075675-24-CPN74692 Effective for dates of service on and after July 1, 2025, the following non-emergency transportation code requires preapproval through Carelon Medical Benefits Management. CPT® code | Description | A0425 | Ground mileage, per statute mile |
As a reminder, ordering and servicing providers may submit preapproval requests to Carelon Medical Benefits Management in one of several ways: - Visit Carelon Medical Benefits Management’s 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 via https://Availity.com.
If you have questions, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com or visit https://guidelines.carelonmedicalbenefitsmanagement.com. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-078792-25-CPN77989 Beginning May 9, save time and speed up care by submitting federal employee program (FEP) behavioral health (BH) preapprovals through Availity Essentials at https://Availity.com. Accessing Availity Essentials for preapproval is easyAsk your organization’s Availity Essentials administrator to ensure you have the Authorization role assignment so you can access the application. Then, log in at https://Availity.com, select Authorizations and Referrals, and navigate to the Patient Registration tab. If you do not already have an Availity Essentials account, you can create one at https://Availity.com. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-079064-25 Prior Authorization | Anthem Blue Cross and Blue Shield | Medicare Advantage / AMH Health, LLC | Medicare Advantage | March 6, 2025 Prior authorization requirement changesEffective July 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage 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 precertification rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity or by calling Provider Services with additional information which may include medical records. Prior authorization requirements will be added for the following code(s): Code | Description | 0108U | Gastroenterology (Barrett's esophagus), whole slide‑digital imaging, including morphometric analysis, computer‑assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX‑2, CD45RO, HIF1a, HER‑2, K20) and morphology, formalin‑fixed paraffin‑embedded tissue, algorithm reported as risk of progression to high‑grade dysplasia or cancer | 0394U | Perfluoroalkyl substances (PFAS) (for example, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC‑MS/MS), plasma or serum, quantitative | 0457U | Perfluoroalkyl substances (PFAS) (for example, perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC‑MS/MS, plasma or serum, quantitative | 0479U | Tau, phosphorylated, pTau217 | 0480U | Infectious disease (bacteria, viruses, fungi, and parasites), cerebrospinal fluid (CSF), metagenomic next‑generation sequencing (DNA and RNA), bioinformatic analysis, with positive pathogen identification | 0482U | Obstetrics (preeclampsia), biochemical assay of soluble fms‑like tyrosine kinase 1 (sFlt‑1) and placental growth factor (PlGF), serum, ratio reported for sFlt‑1/PlGF, with risk of progression for preeclampsia with severe features within 2 weeks | 0490U | Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular‑weight melanoma‑associated antigen, CD34 and CD45 protein biomarkers, peripheral blood | 0491U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of estrogen receptor (ER) protein biomarker‑expressing cells, peripheral blood | 0492U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of PD‑L1 protein biomarker‑expressing cells, peripheral blood | 0495U | Oncology (prostate), analysis of circulating plasma proteins (tPSA, fPSA, KLK2, PSP94, and GDF15), germline polygenic risk score (60 variants), clinical information (age, family history of prostate cancer, prior negative prostate biopsy), algorithm reported as risk of likelihood of detecting clinically significant prostate cancer | 0503U | Neurology (Alzheimer disease), beta amyloid (AB40, AB42, AB42/40 ratio) and tau‑protein (ptau217, np‑tau217, ptau217/np‑tau217 ratio), blood, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC‑MS/MS), algorithm score reported as likelihood of positive or negative for amyloid plaques | 0517U | Therapeutic drug monitoring, 80 or more psychoactive drugs or substances, LC‑MS/MS, plasma, qualitative and quantitative therapeutic minimally and maximally effective dose of prescribed and non‑prescribed medications | 0518U | Therapeutic drug monitoring, 90 or more pain and mental health drugs or substances, LC‑MS/MS, plasma, qualitative and quantitative therapeutic minimally effective range of prescribed and non‑prescribed medications | 0519U | Therapeutic drug monitoring, medications specific to pain, depression, and anxiety, LC‑MS/MS, plasma, 110 or more drugs or substances, qualitative and quantitative therapeutic minimally effective range of prescribed, non‑prescribed, and illicit medications in circulation | 0915T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator and dual transvenous electrodes/leads (pacing and defibrillation) | 0916T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator only | 0917T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; single transvenous lead (pacing or defibrillation) only | 0918T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; dual transvenous leads (pacing and defibrillation) only | 0919T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); pulse generator only | 0920T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); single transvenous pacing lead only | 0921T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); single transvenous defibrillation lead only | 0922T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); dual (pacing and defibrillation) transvenous leads only | 0923T | Removal and replacement of permanent cardiac contractility modulation‑defibrillation pulse generator only | 0924T | Repositioning of previously implanted cardiac contractility modulation‑defibrillation transvenous electrode(s)/lead(s), including fluoroscopic guidance and programming of sensing and therapeutic parameters | 0925T | Relocation of skin pocket for implanted cardiac contractility modulation‑defibrillation pulse generator | 0926T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation‑defibrillation system | 0927T | Interrogation device evaluation (in person) with analysis, review, and report, including connection, recording, and disconnection, per patient encounter, implantable cardiac contractility modulation‑defibrillation system | 0928T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation‑defibrillation system with interim analysis and report(s) by a physician or other qualified health care professional | 0929T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation‑defibrillation system, remote data acquisition(s), receipt of transmissions, technician review, technical support, and distribution of results | 0930T | Electrophysiologic evaluation of cardiac contractility modulation‑defibrillator leads, including defibrillation‑threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), at time of initial implantation or replacement with testing of cardiac contractility modulation‑defibrillator pulse generator | 0931T | Electrophysiologic evaluation of cardiac contractility modulation‑defibrillator leads, including defibrillation‑threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), separate from initial implantation or replacement with testing of cardiac contractility modulation‑defibrillator pulse generator | 0933T | Transcatheter implantation of wireless left atrial pressure sensor for long‑term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation | 0934T | Remote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data from daily uploads of left atrial pressure recordings, interpretation(s) and trend analysis, with adjustments to the diuretics plan, treatment paradigm thresholds, medications or lifestyle modifications, when performed, and report(s) by a physician or other qualified health care professional | 0935T | Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of ureteral sheath(s) and multiple conformable electrodes, contrast injection(s), and fluoroscopy, bilateral | 82542 | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | 83921 | Organic Acid, Single, Quantitative | 93701 | Bioimpedance‑derived physiologic cardiovascular analysis | A2027 | Matriderm, per square centimeter | A2028 | Micromatrix flex, per mg | A2029 | Mirotract wound matrix sheet, per cubic centimeter | A4543 | Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month | A4544 | Electrode for external lower extremity nerve stimulator for restless legs syndrome | E0738 | Upper extremity rehabilitation system providing active assistance to facilitate muscle re‑education, includes microprocessor, all components and accessories | J9248 | Injection, melphalan (Hepzato), 1 mg | L5783 | Addition to lower extremity, user adjustable, mechanical, residual limb volume management system | L5841 | Addition, endoskeletal knee‑shin system, polycentric, pneumatic swing, and stance phase control |
Not all PA requirements are listed here. Contracted providers can access the information at https://Availity.com. UM AROW A2024M2893 Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Plans offered by AMH Health, LLC., a joint venture between MaineHealth and Anthem Partnership Holding Company, LLC. AMH Health is an independent licensee of the Blue Cross Blue Shield Association. MEBCBS-CR-076900-25-CPN76474 Pharmacy | Anthem Blue Cross and Blue Shield | Commercial | April 1, 2025 Notice of material change/amendment to contract Specialty pharmacy updates — April 2025Your patients may be receiving medications listed in the tables below without preapproval. As of July 1, 2025, you may need to request a preapproval review to ensure your patients’ continued use of these medications. Including the National Drug Code (NDC) on your claim will help us process claims more quickly for drugs billed with a not otherwise classified (NOC) code. Preapproval updates Effective for dates of service on or after July 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our preapproval review process. Access our Clinical Criteria to view the complete information for these preapproval updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0272 | Aucatzyl (obecabtagene autoleucel) | C9399, J9999 | CC-0274* | Bizengri (zenocutuzumab-zbco) | C9399, J9999 | CC-0041 | Bkemv (eculizumab-aeeb) | Q5139 | CC-0058 | Bynfezia Pen (octreotide acetate) | C9399, J3490 | CC-0041 | Epysgli (eculizumab-aagh) | J3590 | CC-0149 | Hympavzi (marstacimab-hncq) | C9399, J3590 | CC-0063 | Imuldosa (ustekinumab-srlf) | J3590 | CC-0063 | Otulfi (ustekinumab-aauz) | J3590 | CC-0063 | Pyzchiva IV (ustekinumab-ttwe) | Q9997 | CC-0063 | Pyzchiva SC (ustekinumab-ttwe) | Q9996 | CC-0063 | Selarsdi (ustekinumab-aekn) | Q9998 | CC-0128* | Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) | C9399, J9999 | CC-0276 | Tryngolza (olezarsen) | C9399, J3490 | CC-0273* | Vyloy (zolbetuximab-clzb) | C9399, J9999 | CC-0063 | Yesintek (ustekinumab-kfce) | J3590 | CC-0275* | Ziihera (zanidatamab-hrii) | C9399, J9999 |
*Carelon Medical Benefits Management manages oncology use. Note: Preapproval requests for certain medications may require additional documentation to determine medical necessity. Step therapy updates Effective for dates of service on or after July 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our specialty pharmacy medical step therapy review process. Access our Clinical Criteria to view the complete information for these step therapy updates. Clinical Criteria | Status | Drug | HCPCS or CPT code(s) | CC-0063 | Non-preferred | Imuldosa (ustekinumab-srlf) | J3590 | CC-0063 | Non-preferred | Otulfi (ustekinumab-aauz) | J3590 | CC-0063 | Non-preferred | Pyzchiva IV (ustekinumab-ttwe) | Q9997 | CC-0063 | Non-preferred | Pyzchiva SC (ustekinumab-ttwe) | Q9996 | CC-0063 | Non-preferred | Selarsdi (ustekinumab-aekn) | Q9998 | CC-0063 | Non-preferred | Wezlana IV (ustekinumab-auub) | Q5138 | CC-0063 | Non-preferred | Wezlana SC (ustekinumab-auub) | Q5137 | CC-0072 | Non-preferred | Ahzantive (aflibercept-mrbb) | J3590, C9399 | CC-0072 | Non-preferred | Enzeevu (aflibercept-abvz) | J3590, C9399 | CC-0072 | Non-preferred | Opuviz (aflibercept-yszy) | J3590, C9399 | CC-0072 | Non-preferred | Yesafili (aflibercept-jbvf) | J3590, C9399 | CC-0072 | Preferred | Pavblu (aflibercept-ayyh) | J3590, C9399 |
Note: Preapproval requests for certain medications may require additional documentation to determine medical necessity. Quantity limit updates Effective for dates of service on or after July 1, 2025, 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) | CC-0274 | Bizengri (zenocutuzumab-zbco) | C9399, J9999 | CC-0058 | Bynfezia Pen (octreotide acetate) | C9399, J3490 | CC-0063 | Imuldosa (ustekinumab-srlf) | J3590 | CC-0063 | Otulfi (ustekinumab-aauz) | J3590 | CC-0063 | Pyzchiva IV (ustekinumab-ttwe) | Q9997 | CC-0063 | Pyzchiva SC (ustekinumab-ttwe) | Q9996 | CC-0063 | Selarsdi (ustekinumab-aekn) | Q9998 | CC-0276 | Tryngolza (olezarsen) | C9399, J3490 | CC-0063 | Yesintek (ustekinumab-kfce) | J3590 |
Pharmacy | Anthem Blue Cross and Blue Shield | Medicare Advantage / AMH Health, LLC | Medicare Advantage | March 19, 2025 Medicare Part B preapproval expands with new drug additionsEffective for dates of service on and after July 1, 2025, the specialty Medicare Part B drugs listed below will be included in our preapproval review process. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these preapproval rules and must be considered first when determining coverage. Please follow the new requirements to ensure your claims are accepted. HCPCS or CPT® codes | Medicare Part B drugs | C9399, J9999 | Aucatzyl (obecabtagene autoleucel) | Q5139 | Bkemv (eculizumab-aeeb) | J3590 | Epysqli (eculizumab-aagh) | C9399, J3590 | Hympavzi (marstacimab-hncq) | J3590 | Imuldosa (ustekinumab-srlf) | J3590 | Otulfi (ustekinumab-aauz) | Q9997 | Pyzchiva IV (ustekinumab-ttwe) | Q9998 | Selarsdi (ustekinumab-aekn) | C9399, J9999 | Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) | C9399, J9999 | Vyloy (zolbetuximab-clzb) |
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-077630-25-CPN77426 |