 Provider News MaineAugust 2022 Anthem Maine Provider NewsNotices 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:
- Reimbursement policy update: Place of Service - Facility
- Medical policy and clinical guideline updates are available on anthem.com
- Specialty pharmacy updates
- Clinical criteria updates for specialty pharmacy
Anthem would like to remind you of the procedures to follow if an inpatient claim is denied.
If a claim is billed with an inpatient bill type in error:
A replacement bill xx7 is a replacement of the same type of bill (example: x11 and x17 or x31 and x37; you may not use an x37 to replace an x11 or an x17 to replace an x31)
- If you are changing the bill type from inpatient to outpatient, or from outpatient to inpatient, the original claim needs to be voided by using a frequency type 8 (void).
- The void request must be submitted first by the provider, or in conjunction with a frequency type 1 (original) inpatient or outpatient claim before the outpatient bill type claim will be processed.
- This can be done electronically or with a provider adjustment request (PAR) form.
- Further instructions are available in the provider manual.
It is inappropriate to re-bill commercial outpatient claims when receiving a denial/upheld appeal response for ancillary services rendered in the inpatient setting. This includes but is not limited to emergency department, imaging, laboratory services, specialty pharmacy, and surgeries.
Claims should be coded and billed based on the medical record and the physician’s order.
For complete information on electronic claims processing procedures, visit our EDI website.
Submitting your updates promptly helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information we show in our online directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Using this form, you can update:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging that we received your request. See the Provider Maintenance Form for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
Anthem appreciates the feedback you shared about the Availity Essentials* multi-payer authorization application. The insight you provided about your user experience has enabled enhancements that we hope will further improve your experience:
- Easier to track your authorization requests: Case numbers are being returned following your authorization submission, making it easier to track your authorization requests.
- Expanded procedure code options: You can now submit your procedure codes by visits and hours, in addition to days and units.
- Error code improvements: Recognizing that error codes can be difficult to understand, we have rewritten them to be more clear, concise, and actionable.
- Enhancements to the admissions dropdown menu: For outpatient submissions, an enhancement to the level of service improves turnaround time for case decision. For inpatient and outpatient submissions, urgent requests receive a confirmation message.
- Update to Add Attachment feature: We have added a reminder notification that enables you to double check that the attachments are connected to the correct member for the correct authorization.
Become an Availity Essentials user today
If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for our providers to register or to use any of the digital applications. Start by logging onto www.availity.com and selecting the Register icon at the top of the home screen.
Now open for learning!
Access to training for Availity Essentials can be helpful when trying to master applications like claims attachments, authorizations and eligibility and benefits. The Provider Learning Hub on anthem.com is not only a new way to access training, it also offers a new learning experience.
Short, easy to follow training videos with supporting resources are available on the Provider Learning Hub – no username and password required. Access it at your convenience and share your learnings with others on your teams. Handy filtering options enable you to quickly find what you are looking for including an option to save trainings to a Favorites folder for easy access later. You will register for the Provider Learning Hub once. On future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today
Access the Provider Learning Hub using this link or from Anthem.com under Important Announcements on the home page.
Digital claims attachments expedite claims processing and payment. That’s why we have been hard at work making the digital attachment process easier, more intuitive and streamlined. Now you can add attachments directly to your claim by using the new Send Attachments feature from the Claims Status application on Availity.com.
Submitting attachments electronically:
- Reduces costs associated with manual submission
- Reduces errors associated with matching the claim when attachments are submitted manually
- Reduces delays in payments
- Saves time because there is no need to copy, fax, or mail
- Reduces the exchange of unnecessary member information and personal health information
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the Attachment Control Number, there are three options for submitting attachments:
- Through the Attachments Dashboard Inbox:
- From com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox
- Through the 275 attachment:
- Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment
- Through the Availity.com application:
- From Availity.com, select the Claims & Payments tab to access Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
If you submitted your claim through the Availity Essentials application:
- Simply submit your attachment with your claim
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and access Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
Learn more about the Send Attachment feature
In collaboration with Availity Essentials, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up for a live webinar today:
- August 9, 2022, 11 a.m. to 12 p.m. Eastern time
- August 10, 2022, 3 p.m. to 4 p.m. Eastern time
Reductions in missed appointments are significant.
Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,1” experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.
Rate of missed appointments before and after transitioning to telehealth
The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.
https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390
“While there are a number of limitations to consider regarding this data, [which is further discussed in the study], the statistically significant reduction in missed appointments pre-and-post [digital] transition is striking,” cited in the study report.
Telehealth and telephone visits with members after a behavioral health inpatient stay meet HEDIS® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution.2
The FUH HEDIS measure evaluates:
- Members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.
Two areas of importance for this HEDIS measure are:
- The percentage of behavioral health inpatient discharges for which the member received follow-up within seven days after discharge
- The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.
These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of rehospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the National Committee for Quality Assurance (NCQA) website.
The following new and revised medical policies and clinical guidelines were endorsed at the May 12, 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
Archived medical policy effective May 19, 2022
(The following policy has been archived.)
- SURG.00101 Suprachoroidal Injection of a Pharmacologic Agent
Archived medical policy effective June 29, 2022
(The following policy has been archived and its content has been transitioned to an existing Clinical UM Guideline.)
- MED.00121 Implantable Interstitial Glucose Sensors [Note: Content transitioned to CG-DME-42 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps.]
Revised medical policies effective June 29, 2022
(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
- GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- GENE.00056 Gene Expression Profiling for Bladder Cancer
- LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
Revised medical policies effective June 29, 2022
(The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
- MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
Archived medical policies effective July 6, 2022
(The following policies have been archived.)
- DME.00024 Transtympanic Micropressure
- SURG.00137 Focused Microwave Thermotherapy for Breast Cancer
Archived medical policy effective July 6, 2022
(The following policy has been archived and its content has been transitioned to a new Clinical UM Guideline.)
- MED.00127 Chelation Therapy [Note: Content transitioned to clinical UM guideline CG-MED-90 Chelation Therapy.]
Revised medical policy effective July 6, 2022
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00097 Scoliosis Surgery
Revised medical policies effective July 6, 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.00002 Preventive Health Guidelines
- ADMIN.00004 Medical Necessity Criteria
- ADMIN.00005 Investigational Criteria
- ADMIN.00007 Immunizations
- ANC.00006 Biomagnetic Therapy
- ANC.00007 Cosmetic and Reconstructive Services: Skin Related
- ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin
- DME.00012 Intrapulmonary Percussive Ventilation Devices
- DME.00030 Altered Auditory Feedback Devices for Fluency Disorders
- DME.00037 Cooling Devices and Combined Cooling/Heating Devices
- DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
- DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
- GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00041 Genetic Testing to Confirm the Identity of Laboratory Specimens
- GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
- GENE.00057 Gene Expression Profiling for Idiopathic Pulmonary Fibrosis
- LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders
- LAB.00029 Rupture of Membranes Testing in Pregnancy
- LAB.00031 Advanced Lipoprotein Testing
- LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
- LAB.00038 Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
- LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline
- MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
- MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease
- MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
- MED.00098 Hyperoxemic Reperfusion Therapy
- MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
- MED.00133 Ingestion Event Monitors
- MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion
- OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis
- OR-PR.00005 Upper Extremity Myoelectric Orthoses
- OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices
- RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
- RAD.00063 Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
- SURG.00005 Partial Left Ventriculectomy
- SURG.00007 Vagus Nerve Stimulation
- SURG.00037 Treatment of Varicose Veins (Lower Extremities)
- SURG.00045 Extracorporeal Shock Wave Therapy
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
- SURG.00071 Percutaneous and Endoscopic Spinal Surgery
- SURG.00076 Nerve Graft after Prostatectomy
- SURG.00084 Implantable Middle Ear Hearing Aids
- SURG.00095 Viscocanalostomy and Canaloplasty
- SURG.00105 Bicompartmental Knee Arthroplasty
- SURG.00111 Axial Lumbar Interbody Fusion
- SURG.00116 High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
- SURG.00118 Bronchial Thermoplasty
- SURG.00120 Internal Rib Fixation Systems
- SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
- SURG.00126 Irreversible Electroporation
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- SURG.00134 Interspinous Process Fixation Devices
- SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization
- SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy
- SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
- SURG.00147 Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
- SURG.00155 Cryoneurolysis
- THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
- TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
Archived medical policy effective September 12, 2022
(The following policy has been archived and has been replaced by AIM guidelines.)
- DME.00039 Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea)
New medical policies effective November 1, 2022
(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.00046 Intermittent Abdominal Pressure Ventilation Devices*
- DME.00047 Rehabilitative Devices with Remote Monitoring*
- DME.00048 Virtual Reality-Assisted Therapy Systems*
- GENE.00059 Hybrid Personalized Molecular Residual Disease Testing for Cancer*
- LAB.00048 Pain Management Biomarker Analysis*
- MED.00139 Electrical Impedance Scanning for Cancer Detection*
- TRANS.00039 Portable Normothermic Organ Perfusion System*
Revised medical policy effective November 1, 2022
(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- GENE.00023 Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma*
- LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests*
Clinical guideline updates
Revised clinical guideline effective June 29, 2022
(The following adopted guideline was updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
- CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management
Revised clinical guideline effective July 6, 2022
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
Revised clinical guidelines effective July 6, 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-DME-45 Ultrasound Bone Growth Stimulation
- CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
- CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules
- CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
- CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
- CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
- CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
- CG-MED-89 Home Parenteral Nutrition
- CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
- CG-SURG-27 Gender Affirming Surgery
- CG-SURG-71 Reduction Mammaplasty
- CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
- CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
- CG-SURG-85 Hip Resurfacing
- CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus
- CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
Revised clinical guidelines effective November 1, 2022
(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-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver*
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention*
Beginning with dates of service on or after November 1, 2022, Anthem will update the policy language to indicate the following:
- The title of the policy will be renamed Place of Service – Facility. The previous policy title was Place of Service Evaluation and Management Services – Facility.
- Professional services billed under revenue codes 960-983 are nonreimbursable when submitted on a UB-04, excluding revenue code 964.
- Preventive Counseling CPT codes 99406 – 99409, 99411, 99412 are nonreimburseable when billed in an outpatient setting.
As a reminder, Evaluation and Management (E/M) services and other professional services (excluding E/M services rendered in the emergency room and billed with ER revenue codes) are required to be billed on a CMS 1500 form.
For specific policy details, visit the reimbursement policy page at anthem.com.
Specialty pharmacy updates for Anthem are listed below.
Anthem’s medical specialty drug review team manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. 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. Effective November 1, 2022, you may be required to request prior authorization review for your patients’ continued use of these medications.
By including the National Drug Code (NDC) on your claim, you 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 November 1, 2022, 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-0072+
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590
|
|
ING-CC-0107*+
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0216*+
|
Opdualag (nivolumab and relatlimab-rmbw)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0118*+
|
Pluvicto (lutetium lu 177 vipivotide tetraxetan)
|
A9699
|
|
ING-CC-0002*+
|
Releuko (filgrastim-ayow)
|
C9096
|
Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after November 1, 2022, 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.
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
|
Releuko
|
C9096
|
|
ING-CC-0107*
|
Non-preferred
|
Alymsys
|
C9399, J3490, J3590, J9999
|
Courtesy notice
Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.
Quantity limit updates
Effective for dates of service on and after November 1, 2022, 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-0072
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590
|
The following clinical criteria documents were endorsed at the May 20, 2022, clinical criteria meeting. Visit our website to access the clinical criteria information.
Revised clinical criteria effective May 20, 2022
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
- ING-CC-0148 Agents for Hemophilia B
New clinical criteria effective June 2, 2022
The following clinical criteria is new:
- ING-CC-0216 Opdualag (nivolumab and relatlimab-rmbw)
Revised clinical criteria effective June 2, 2022
The following clinical criteria was revised to expand medical necessity indications or criteria:
- ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
Revised clinical criteria effective June 20, 2022
The following clinical criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
- ING-CC-0092 Adcetris (brentuximab vedotin)
- ING-CC-0106 Erbitux (cetuximab)
- ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0116 Bendamustine agents
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
- ING-CC-0145 Libtayo (cemiplimab-rwlc)
- ING-CC-0151 Yescarta (axicabtagene ciloleucel)
Revised clinical criteria effective June 20, 2022
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0045 Increlex (mecasermin)
- ING-CC-0057 Krystexxa (pegloticase)
- ING-CC-0069 Egrifta (tesamorelin)
- ING-CC-0098 Doxorubicin Liposome (Doxil, Lipodox)
- ING-CC-0105 Vectibix (panitumumab)
- ING-CC-0111 Nplate (romiplostim)
- ING-CC-0114 Jevtana (cabazitaxel)
- ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- ING-CC-0128 Tecentriq (atezolizumab)
- ING-CC-0134 Provenge (sipuleucel-T)
- ING-CC-0137 Cablivi (caplacizumab-yhdp)
- ING-CC-0142 Somatuline Depot (lanreotide)
- ING-CC-0160 Vyepti (eptinezumab)
- ING-CC-0161 Sarclisa (isatuximab-irfc)
- ING-CC-0162 Tepezza (teprotumumab-trbw)
- ING-CC-0165 Trodelvy (sacituzumab govitecan)
- ING-CC-0166 Trastuzumab Agents
- ING-CC-0169 Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
- ING-CC-0178 Synribo (omacetaxine mepesuccinate)
- ING-CC-0188 Imcivree (setmelanotide)
- ING-CC-0192 Cosela (trilaciclib)
- ING-CC-0199 Empaveli (pegcetacoplan)
Revised clinical criteria effective July 1, 2022
The following clinical criteria were updated with new procedure and/or diagnosis codes:
- ING-CC-0003 Immunoglobulins
- ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
- ING-CC-0205 Fyarro (sirolimus albumin bound)
- ING-CC-0207 Vyvgart (efgartigimod alfa-fcab)
- ING-CC-0209 Leqvio (inclisiran)
- ING-CC-0210 Enjaymo (sutimlimab-jome)
- ING-CC-0211 Kimmtrak (tebentafusp-tebn)
- ING-CC-0212 Tezspire (tezepelumab-ekko)
- ING-CC-0214 Carvykti (ciltacabtagene autoleucel)
Revised clinical criteria effective August 1, 2022
The following clinical criteria was updated with new procedure and/or diagnosis codes:
- ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
New clinical criteria effective November 1, 2022
The following clinical criteria is new:
- ING-CC-0215 Ketamine injection (Ketalar)*
Revised clinical criteria effective November 1, 2022
The following clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:
- ING-CC-0002 Colony Stimulating Factor Agents*
- ING-CC-0032 Botulinum Toxin*
- ING-CC-0068 Growth Hormone*
- ING-CC-0087 Gamifant (emapalumab-lzsg)*
- ING-CC-0092 Adcetris (brentuximab vedotin)*
- ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications*
- ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)*
- ING-CC-0119 Yervoy (ipilimumab)*
- ING-CC-0124 Keytruda (pembrolizumab)*
- ING-CC-0145 Libtayo (cemiplimab-rwlc)*
- ING-CC-0153 Adakveo (crizanlizumab)*
- ING-CC-0175 Proleukin (aldesleukin)*
- ING-CC-0201 Rybrevant (amivantamab-ymjw)*
The following clinical criteria document was endorsed at the June 23, 2022, clinical criteria meeting. Visit our website to access the clinical criteria information.
Revised clinical criteria effective November 1, 2022
The following clinical criteria was revised and might result in services that were previously covered but may now be found to be not medically necessary:
- ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors*
Visit the Drug Lists page on anthem.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes
- Drug lists and changes
- Prior authorization criteria
- Procedures for generic substitution
- Therapeutic interchange
- Step therapy or other management methods subject to prescribing decisions
- Any other requirements, restrictions, or limitations that apply to using certain drugs
The commercial and Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July and October.
To locate “Exchange Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
|