 Provider News MissouriNovember 2024 Provider NewsletterSummary:- The Anthem Alliance provider network will dissolve effective January 1, 2025.
- No action is required of care providers.
The Anthem Alliance provider network will dissolve effective January 1, 2025. There is no action required of you. We highly value your current participation as an Anthem provider. We are committed to providing affordable, quality healthcare options that our members request and deserve. As such, we will continue to collaborate with members to maintain access to networks that are designed to control costs and produce desired healthcare outcomes. If you have questions regarding this change, contact Sonya Patterson, Network Relations Consultant Sr., at sonya.patterson@anthem.com. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MOBCBS-CM-072065-24 The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services. If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services. If you have questions about submitting your information, please see the instructions below. If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here. Begin your application here. To update your application: - Log in to Availity Essentials.
- Select My Providers.
- Select Provider Data Management.
Please update your telehealth information at the service location. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-069888-24-CPN69222 In July, we announced an enhancement to the 277CA to notify you of submission errors discovered during claims processing.
As of November 1, 2024, the 277CA will include additional corrective action types for your review. As communicated in July, these errors will still be sent through physical mailing.
With these added error types, there is no reduction to the services we already provide.
Through our efforts, we are committed to reducing administrative burden, improving communication, and ensuring timely payments because we value you, our care provider partners.
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-069544-24-CPN69313 Beginning with claims processing on or after December 1, 2024, we will update our outpatient facility claims editing process to deny claim lines when an add-on code is reported without a primary procedure code. An add-on code is a specific type designated by the HCPCS or CPT®. These codes describe additional procedures or services performed with a primary procedure. According to CPT guidelines, add-on codes must be reported with a primary procedure code. If you believe you have received a claim denial in error, please follow our claim dispute process. With your help, we can continually build towards a future of shared success. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-070181-24-CPN69226 Find Care, the doctor finder and transparency tool in the Anthem online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options such as sorting providers based on distance, alphabetical order, and provider name. In our November 2022 newsletter, we provided an update regarding Personalized Match, an additional Find Care sorting option for Commercial members. We informed you that this provider sorting option was based on provider efficiency and quality outcomes described in a methodology document linked in the newsletter article, in addition to member search radius. We want to inform you that, beginning in December 2024 or later, we will be enhancing Personalized Match. This will expand upon the existing program. Newer components of the provider personalization metrics will contain up to 10 times as many features as compared to existing metrics such as gaps in care and additional types of service cost and utilization. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius, first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name. Helpful resources on AvailityYou may review a copy of the Personalized Match methodology that has been posted on Availity, our secure web-based provider tool, using the following navigation: - Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.
If you have general questions regarding these upcoming changes, please submit an inquiry via the web at Availity.com. If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.com. Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-061391-24, MULTI-BCBS-CM-070287-24 We are in the process of shutting down specific authorization fax channels. This is to notify you that the fax numbers below will be decommissioned on November 15, 2024.
Look for additional notifications as other authorization fax lines are retired.
Availity Essentials is the preferred method for authorization intakes. If you cannot use Availity Essentials, call our contact center at 833-545-9102, and we will work with you to determine the best submission method.
Available resources
Registering and accessing Availity Essentials is easy. If your organization is not registered for Availity Essentials, see Register and get started with Availity Essentials (Availity.com).
If you are not already familiar with Availity Essentials, training is available. Register for training today. Under Help and Learning, select Get Trained and learn about the simple workflow for submitting digital authorizations.
These fax numbers will be turned off on November 15, 2024.
800-773-7797
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800-266-3504
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866-959-1393
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877-254-4971
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866-959-1395
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404-467-2600
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404-842-8390
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404-848-2448
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804-354-2578
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804-354-3307
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804-354-3882
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804-678-0650
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In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-070105-24 Anthem has a continued mission to leverage digital technology to provide enhanced services for both members and care providers. We encourage the support of care providers in accepting digital ID cards instead of a physical member ID card. As members increasingly use digital ID cards, care providers may need to implement changes in their processes to accept this format. Due to recent enhancements, care providers can bypass the request for cards by accessing Availity.com. If a copy of a physical member identification card is needed, a member can email, fax, or access card details saved in their digital wallet. As a reminder, care providers can also access eligibility and benefit information without the health care identification (HCID). This makes both check-ins and submitting claims easier and faster. Anthem is dedicated to providing digital solutions that transform both care provider and payer interactions. Thank you in advance for your continued partnership and support in empowering our members to use their digital ID cards. With your help, we can continually build towards a future of shared success. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-069066-24, MULTI-BCBS-CM-077976-25 We are excited to announce the release of an Applied Behavior Analysis (ABA) Provider Resource Guide designed to assist with proper billing and documentation practices. This essential guide simplifies the complexities of ABA coding and requirements, ensuring that you can navigate these processes with ease. Refer to attached ABA Provider Resource Guide. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-072382-24-CPN72379 ATTACHMENTS (available on web): ABA Provider Resource Guide - Anthem Blue Cross Blue Shield (pdf - 0.39mb) As a contracted provider for a special needs plan (SNP) from Anthem, you are required to participate in an annual Model of Care training for providers, per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information, highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members, ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes. Training for the SNP product is self-paced and available at Availity.com. The training must be completed by December 31, 2024. How to access the Custom Learning Center:- Log in to the Availity website at Availity.com.
- At the top of the Availity website, select Payer Spaces and select the appropriate payer.
- On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
- In the Custom Learning Center, select Required Training.
- Select Special Needs Plan and Model of Care Overview.
- Select Enroll.
- Select Start.
- Once the course is completed, select Begin Attestation and complete.
Not registered for Availity Essentials?Have your organization’s designated administrator register your organization for the Availity website: - Visit Availity.com to register.
- Select Register.
- Select your organization type.
- In the Registration wizard, follow the prompts to complete the registration for your organization.
Refer to these PDF documents for complete registration instructions. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-070560-24-CPN70218 Effective January 1, 2025, Conservation Employees’ Benefits Plan Trust Fund (CEBP) in Missouri will offer a Medicare Preferred Provider Organization (PPO) plan through Anthem. Anthem will provide medical benefits for CEBP retirees through the PPO product, which includes the National Access Plus benefit. The PPO plan allows members to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. CEBP members’ copay or coinsurance percentage will be the same whether their provider is in-network or out-of-network. Locally or nationwide, doctors or hospitals, member share of cost (SOC) does not change. Non-contracted providers may continue treating CEBP members and will be reimbursed 100% of Medicare’s allowed amount for covered services. The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers while covering additional benefits that Medicare does not, such as LiveHealth Online and SilverSneakers. The prefix on the Medicare Advantage ID cards is ZMX. Detailed prior authorization requirements are also available to contracted providers by accessing the Provider Self-Service Tool on the Availity website at Availity.com. Providers will follow their normal claim filing procedures for CEBP member claims. Providers may call Provider Services at 833-848-8730 for eligibility, prior authorization requirements, and any questions about the CEBP member benefits or coverage. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MOBCBS-CR-069326-24 In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care, effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements. You may access and download a copy of the current and upcoming guidelines here. Site of Care Guidelines: - Site of Care for Advanced Imaging
- Rehabilitative Site of Care
- Surgical Site of Care
Please share this notice with other members of your practice and office staff. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-067576-24-CPN67268 Effective November 17, 2024 This article was updated on November 24, 2024 to change the effective date from October 26, 2024 to November 17, 2024. Effective on November 17, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement. You may access and download a copy of the current and upcoming guidelines here: - Musculoskeletal:
- Site of Care:
- Site of Care for Advanced Imaging
- Rehabilitative Site of Care
- Surgical Site of Care
The above guideline updates have a publish date of November 17, 2024. Please share this notice with other members of your practice and office staff. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-065139-24-CPN64434, MULTI-ALL-CR-074348-24 Effective February 1, 2025 Effective February 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. Non‑compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Code description | 0456U | Autoimmune (rheumatoid arthritis), next-generation sequencing (NGS), gene expression testing of 19 genes, whole blood, with analysis of anti-cyclic citrullinated peptides (CCP) levels, combined with sex, patient global assessment, and body mass index (BMI), algorithm reported as a score that predicts nonresponse to tumor necrosis factor inhibitor (TNFi) therapy PrismRA®, Scipher Medicine®, Scipher Medicine® | 0459U | β-amyloid (Abeta42) and total tau (tTau), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology Elecsys® Total Tau CSF (tTau) and β-Amyloid (1-42) CSF II (Abeta 42) Ratio, Roche Diagnostics Operations, Inc (US owner/operator) | 0468U | Hepatology (nonalcoholic steatohepatitis [NASH]), miR-34a5p, alpha 2-macroglobulin, YKL40, HbA1c, serum and whole blood, algorithm reported as a single score for NASH activity and fibrosis NASHnext™ (NIS4™), Labcorp, Labcorp | J0687 | Injection, cefazolin sodium (WG Critical Care), not therapeutically equivalent to J0690, 500 mg | J0688 | Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg | J0689 | Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg | J0744 | Injection, ciprofloxacin for intravenous infusion, 200 mg | J2183 | Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mg | J2184 | Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mg | J2281 | Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mg |
Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at the number on the back of the patient’s member ID card for assistance with PA requirements. UM AROW #: A2024M2186 In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-068215-24-CPN67511 As a reminder, and as previously communicated through letters we mailed to participating facilities on October 1, 2021, we allow reimbursement for only the primary or highest-valued procedure when multiple or bilateral procedures are performed on the same day or same session and at the same place of treatment when billed by a facility. A single surgical procedure is subject to multiple procedure reduction guidelines when submitted with multiple units. For specific Multiple Surgery — Facility reimbursement policy details, visit the reimbursement policy page at https://tinyurl.com/ee8v39r9. With your help, we can continually build towards a future of shared success. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MOBCBS-CM-068273-24-CPN68051 Beginning with dates of service on or after February 1, 2025, Anthem will update the Nurse Practitioner and Physician Assistant Services — Professional reimbursement policy as indicated below. The following services will be removed from the policy and are eligible for a payment reduction when billed by a nurse practitioner (NP) or physician assistant (PA) provider: - Preventive Services
- Radiology Services
The following services will be added to the policy and will not be considered for a payment reduction when billed by a nurse practitioner (NP) or physician assistant (PA) provider: - Drugs
- Durable Medical Equipment, Prosthetics, Orthotics and Supplies
- Laboratory Services and Laboratory Screening Tests
For specific policy details, visit the reimbursement policy page by selecting here. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-069779-24 At a glance: - High Performing Providers will also be known as Anthem Diamond Providers.
- Providers receiving a designation based on the Blue National Physician Performance Dataset will also be known as Anthem Diamond Providers (National).
High Performing Provider programOver the last several months, we have communicated with our providers about our High Performing Provider program. PCPs and specialists meeting certain criteria are designated High Performing Providers. High Performing Providers may also be referred to as Anthem Diamond Providers. As a reminder, the following specialties may be designated High Performing Providers (aka Anthem Diamond Providers) from this program: - PCP: family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, and nurse practitioners
- Specialists: cardiology, endocrinology, nephrology, neurology, neurosurgery, obstetrics gynecology, orthopedic surgery, psychiatry, pulmonology, and rheumatology
If you have any questions about this program, contact Provider Services or your local provider relationship management representative. Blue National Physician Performance DatasetThis is an Anthem designation program for providers in networks supporting Anthem national accounts and certain out-of-area providers. As we previously communicated to you, effective January 1, 2025, Anthem may incorporate insights from the Blue National Physician Performance Dataset (Dataset) in various initiatives. For Anthem national accounts and certain out-of-area providers, Anthem will use data made available in the Dataset to assess individual physician’s performance at the NPI level. The individual physician’s performance is assessed across the three domains — cost of care/efficiency, quality of care, and appropriateness of care — for the following 16 primary care and specialty areas: cardiothoracic surgery, cardiovascular disease, endocrinology, neurology, ob/gyn, ophthalmology, orthopedics, pediatrics, primary care, pulmonology, surgery, urology, gastroenterology, otolaryngology, oncology, and radiation oncology. The providers who qualify for the designation from this Dataset program will also be referred to as Anthem Diamond Providers (National). If you have any questions regarding this, contact your local provider relationship management representative. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-070326-24 This article was updated on October 9, 2024, to remove Ilumya as non-preferred from the step therapy requirements section below. Ilumya is not being added to the step therapy program at this time. Specialty pharmacy updates for Anthem are listed below. Anthem’s medical specialty drug review team manages prior authorization (PA) clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., 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 PA 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 or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our PA review process. Access our Clinical Criteria to view the complete information for these prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT® Code(s) | CC-0003* | Alyglo (immune globulin intravenous, human-stwk) | J1599 | CC-0062 | Simlandi (adalimumab-ryvk) | J3590 | CC-0261 | Winrevair (sotatercept-csrk) | C9399, J3590 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: PA requests for certain medications may require additional documentation to determine medical necessity. Step therapy updates Effective for dates of service on or after October 1, 2024, 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) | CC-0003 | Non-preferred | Alyglo (immune globulin intravenous, human-stwk) | J1599 | CC-0062 | Non-preferred | Cimzia (certolizumab pegol) | J0717 | CC-0042 | Non-preferred | Cosentyx intravenous (secukinumab) | C9399, J3490, J3590, C9166 | CC-0050 | Non-preferred | Omvoh (mirkizumab-mrkz) | C9168, J3590 |
Quantity limit updates Effective for dates of service on or after October 1, 2024, 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-0062 | Simlandi (adalimumab-ryvk) | J3590 | CC-0261 | Winrevair (sotatercept-csrk) | C9399, J3590 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-060687-24-CPN60563, MULTI-BCBS-CM-069897-24 Specialty pharmacy updates for 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 Carelon Medical Benefits Management, Inc., a separate company. 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 the national drug code (NDC) on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code. Prior authorization updatesEffective for dates of service on or after February 1, 2025, 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) | CC-0027* | Jubbonti; Wyost (denosumab-bbdz) | Q5136 | CC-0002* | Nypozi (filgrastim-txid) | C9399, J3590 | CC-0266* | Rytelo (imetelstat) | C9399, J9999 | CC-0003* | Yimmugo (immune globulin intravenous, human–dira) | J3590 |
* Oncology use is managed by Carelon Medical Benefits Management. Step therapy updatesEffective for dates of service on or after February 1, 2025, 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. The current Orencia step therapy preferred product list under the medical benefit is being modified to include only those that are considered medical benefit drugs. Access our Clinical Criteria to view the complete information for these step therapy updates. Clinical Criteria | Status | Drug | HCPCS or CPT code(s) | CC-0002 | Non-preferred | Nypozi | C9399, J3590 | CC-0003 | Non-preferred | Yimmugo | J3590 |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Site of care updatesEffective for dates of service on and after February 1, 2025, 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) | CC-0003 | Alyglo (immune globulin intravenous, human-stwk) | J1599 | CC-0066 | Tyenne (tocilizumab-aazg) | Q5135 |
Quantity limit updatesEffective for dates of service on or after February 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-0266 | Rytelo (imetelstat) | C9399, J9999 | CC-0027 | Jubbonti; Wyost (denosumab-bbdz) | Q5136 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-069728-24-CPN69536 Enhanced adherence mitigates healthcare costs and improves patient outcomes and quality of life. Promoting medication adherence and advocating for statin use among diabetes patients is critical. Statin use in diabetes:- Diabetics are two to four times more likely to die from heart disease (American Heart Association).
- Statins lower LDL cholesterol, reducing cardiovascular events by 25 to 60%.
- Statin use is low, particularly in younger, female, and black individuals.
- Delayed statin use increases cardiovascular disease risk in diabetic patients.
- National guidelines recommend statin therapy for diabetics ages 40 to 75, regardless of LDL levels.
- CMS has adopted the Statin Use in Persons with Diabetes (SUPD) measure to combat cardiovascular death in diabetic patients.
Medication adherence:- Poor adherence increases morbidity and mortality, causing more than 125,000 deaths and 10% of hospitalizations annually in the United States.
- Forty-five percent of U.S. adults have hypertension and only 24% manage it effectively, largely due to non-adherence.
- High adherence in diabetic patients reduces hospitalization risks by 30%.
- Improved adherence can save $1,200 to $8,000 per patient annually.
Supporting patients:- Simplify the regimen: Prescribe medications with fewer daily doses.
- Regular follow-ups: Ensure correct medication use and adjust doses as needed.
- Clear communication: Explain medication benefits, risks of non-compliance, and side effects.
- Extended prescriptions: Provide 90 to 100 days’ supply and sufficient refills.
- Home delivery: Eliminate transportation barriers.
- Address statin hesitancy: Discuss pros and cons and involve family in decisions.
- Use technology: Set up reminders through mobile apps, SMS, email, or pill containers.
- Address cost issues: Prescribe affordable options and explore assistance programs.
- Personalized care: Tailor medication plans to the patient's lifestyle and needs.
References: - American Diabetes Association Professional Practice Committee. 10. Cardiovascular disease and risk management: Standards of Care in Diabetes—2024. Diabetes Care 2024;47(Suppl. 1):S179–S218
- Bradley CK, Wang TY, Li S, et al. Patient‐Reported Reasons for Declining or Discontinuing Statin Therapy: Insights From the PALM Registry. Journal of the American Heart Association. 2019;8(7). doi: https://doi.org/10.1161/jaha.118.011765
- Wall HK, Ritchey MD, Gillespie C, Omura JD, Jamal A, George MG. Vital Signs: Prevalence of Key Cardiovascular Disease Risk Factors for Million Hearts 2022 — United States, 2011–2016. MMWR Morb Mortal Wkly Rep 2018;67:983–991. doi: http://dx.doi.org/10.15585/mmwr.mm6735a4
- 2 Tarn DM, Barrientos M, Pletcher MJ, et al. Perceptions of Patients with Primary Nonadherence to Statin Medications. The Journal of the American Board of Family Medicine. 2021;34(1):123-131. doi: https://doi.org/10.3122/jabfm.2021.01.200262
- CDC. Statins and Diabetes: What You Should Know. Centers for Disease Control and Prevention. Published January 30, 2023. https://www.cdc.gov/diabetes/library/features/Statins_Diabetes.html
- Kearney PM, Blackwell L, Collins R, et al.; Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008; 371:117–125
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11). doi: https://doi.org/10.1161/cir.0000000000000678
- Collins R, Reith C, Emberson J, et al. The Lancet. 2016;388(10059):2532-2561Interpretation of the evidence for the efficacy and safety of statin therapy. doi: https://doi.org/10.1016/S0140-6736(16)31357-5
- Hla D, Jones R, Blumenthal RS, et al. Assessing severity of statin side effects: Fact vs fiction. American College of Cardiology. April 09, 2018. Accessed May 17, 2023. https://www.acc.org/latest-in-cardiology/articles/2018/04/09/13/25/assessing-severity-of-statin-side-effects
- Reston JT, Buelt A, Donahue MP, Neubauer B, Vagichev E, McShea K. Interventions to Improve Statin Tolerance and Adherence in Patients at Risk for Cardiovascular Disease. Annals of Internal Medicine. 2020;173(10):806-812. doi: https://doi.org/10.7326/m20-4680
- Brown M, Sinsky CA. Medication Adherence. Improve Patient Outcomes and Reduce Costs. American Medical Association Steps Forward. 5 June 2015. https://edhub.ama-assn.org/steps-forward/module/2702595. Accessed 16 May 2023
- Eight reasons patients don’t take their medications. American Medication Association. Feb 22, 2023. Accessed May 17, 2023. https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications
- El Halabi J, Minteer W, Boehmer KR. Identifying and Managing Treatment Nonadherence. Medical Clinics of North America. 2022;106(4):615-626. doi: https://doi.org/10.1016/j.mcna.2022.02.003
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-069868-24-CPN69806 |