CMS average sales price (ASP) first quarter fee schedule with an effective date of January 1, 2021 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on February 1, 2021. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

957-0121-PN-CONV

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized survey conducted between February and May each year to assess consumers’ experience with their provider and health plan.  A random sample of your adult and child patients may receive the survey.  Over half of the questions used for scoring are directly impacted by providers. The survey questions are:

 

• When you needed care right way, how often did you get it?
• How often did you get an appointment for a check-up or routine care as soon as you needed?
• How often was it easy to get the care, tests, or treatment you needed?
• How often did you get an appointment to see a specialist as soon as you needed?
• How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
• How would you rate your personal doctor?
• How would you rate the specialist you see most often?

To learn more about how you can improve the patient experience review What Matters Most: Improving the Patient Experience, an online course for providers and office staff. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most training can be accessed at: www.patientexptraining.com.

 

Your efforts to create an exceptional care experience for your patients will help to strengthen their healthcare journey.

 

 

916-0121-PN-CONV

Anthem recognizes all coding changes from both the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) effective the date provided by the coding source.  This includes the Evaluation and Management (E/M) changes effective January 1, 2021. 

 

The following updates pertaining to Evaluation and Management services have been identified:

• CPT code 99201 (new patient E/M) will be a deleted code.
• CPT codes 99202 through 99215 (new/established E/M) definitions have changed.  Selection of these E/M codes can now be based on either Medical Decision Making or Time.
• CPT code 99417 (prolonged services) and HCPCS Code G2212 (prolonged services) will be recognized as billable codes.  These codes will be payable based on our existing Prolonged Services policy, which will be updated to reflect the new code along with the modifications to existing prolonged service codes CPT codes 99354 and 99355.
• HCPCS Code G2211 (complexity inherent to evaluation and management associated with primary medical care) will not be separately reimbursed for this service.  We will be updating our Bundled Services and Supplies policy to reflect this position. 

 

Additionally, we are in the process of updating reimbursement policies impacted by the E/M service changes such as the Documentation and Reporting Guidelines for Evaluation and Management Services. 

 

 

936-0121-PN-CONV

We would like to educate you on the new national Blue High Performance Network (HPN) utilizing the Nevada Pathway HMO Network to support new product offerings available to starting in January 20201.  These Blue High Performance Network plan offerings will only be available for Pathway HMO Providers.

 

What is Blue High Performance Network (HPN)?

• The Blue High Performance Network is part of a cost and quality solution. It is a tailored network of providers aimed at reducing quality variation and improving cost savings. 
• Blue High Performance Network is part of a Blue Cross and Blue Shield Association (BCBSA) mandate (supported by Anthem) to develop a national network solution aimed at achieving improved cost savings and providing access to high performing providers. ​
• Blue High Performance Network is a next evolution of Anthem’s network strategy that mobilizes every player in healthcare to champion the best in care, experiencesand cost. ​
• On the local side, we are pairing our local high performance network, Pathway HMO, with a medical product and digital product capabilities to create a holistic offering that would empower consumers to make informed healthcare decisions and drive a differentiated member experience.​
• Blue High Performance Network is a national network designed from our local market expertise, deep data and strong provider relationships. These local networks (e.g. Pathway HMO) are then connected to the national chassis to form a national Blue High Performance Network.
• Blue High Performance Network includes in-network coverage from all participating Pathway HMO providers. The only coverage available outside of a Pathway HMO Blue High Performance Network service area is for urgent or emergency care. Otherwise, there is no coverage for services received outside of a high performance network service area or from non-high performing network providers.

 

The reimbursement rates for the Blue High Performance Network will be the same as the Pathway HMO reimbursement rates. 

 

Blue High Performance Network

 

Beginning January 1, 2021 Anthem Blue Cross and Blue Shield will launch Blue High Performance Network in Nevada. Blue High Performance Network is a national network available in over 54 markets across the country. This network will be used to support some Anthem fully insured health benefits plans as well as certain self-funded plans.

 

Note: the local market is referenced as Pathway HMO; and the National market is referenced as Blue High Performance Network.

 

Pathway HMO Member ID Cards

 

Pathway HMO members will be issued a new ID card to identify and access Blue High Performance Network providers.  Virtual ID cards will also be available to members through the Sydney Health and Engage Wellbeing apps.

 

All Blue High Performance Network plan ID cards will reflect Blue High Performance Network (HPN) in a suitcase on the front of the card and a disclaimer on the back of the ID card that reads “Services rendered by a non- Blue High Performance Network provider will be limited to Urgent and Emergent care”. 

 

Identifying Blue High Performance Network members accessing the Pathway HMO Network:

Three-Character Prefix	Suitcase Logo	Health Benefit Plan Option	Product Type	Network Name (On member ID cards)
H8N	HPN in suitcase	Nevada enrollee in Blue HPN	HMO	Pathway HMO
Varies*	HPN in suitcase	Out-of-state enrollee in Blue HPN	PPO/EPO	Network name on ID card will vary, but when accessing care in Nevada, members will utilize Pathway HMO

 

Blue High Performance Network sample member ID card

 

Blue High Performance Network members will be identified by an HPN in the suitcase logo on their member ID card.​

 

Note: The High Performance Network acronym HPN is not used in conjunction or affiliated with any other local organizations known by the same acronym.

 

Virtual ID Cards through the Sydney Mobile app

 

We are excited about collaborating with our Nevada Pathway HMO providers to keep health care affordable. If you have any questions about this network please feel free to contact Network Relations at nvproviderrelations@anthem.com

 

 

932-0121-PN-NV

 

 

Introducing self-service claim denial review on our secure provider portal.

 

Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

 

The Provider Digital Engagement Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits - all in one comprehensive resource. Find it on Anthem.com > Providers > Forms & Guides > Under the Category heading, select Digital Tools > Provider Digital Engagement Supplement.

 

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit Anthem.com and use the Log In button for access to our secure provider portal, or via the Availity EDI website.

 

Accept digital member ID cards

• Save time by accepting the digital member ID card when presented by the member via their App or email.

 

Register for EFT to get funds faster

• Electronic Funds Transfer (EFT) eliminate the need for paper checks. Safe, secure and faster, payments are deposited directly to your bank account. Register here.

Eliminate paper remittances

• Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.

 

We appreciate your health care team going digital with Anthem as of January 1, 2021, enabling us to realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.

 

 

946-0121-PN-CONV

 

Introducing self-service claim denial review on our secure provider portal.

 

Anthem Blue Cross and Blue Shield (Anthem) wants to make your job easier -- and that includes real-time feedback to claim denials. Through predictive analytics, we now have insight into the reasons for claim denial. We have taken that information and streamlined the inquiries by reason codes.  It is available to you digitally, through our secure provider portal.

 

Now, within minutes, you will know why a claim denied. We will also provide the steps needed so you can take action faster to correct the claim.  There is less wait time and faster payment.

There is no need to call for updates or experience unnecessary delays waiting for the explanation of benefit.

 With little more than a click:

• Review a complete list of claims, including claims with proactive insights
• Learn the reasons for claim denial
• Access the information you need to move the claim forward

 

Predictive analytics and self-service claim denial information is just another way Anthem is using digital technology to improve your healthcare experience.

 

From Anthem.com, use the Log In button to access our secure provider portal Availity.com. Go to Payer Spaces, to access Claims Status Listing.

 

 

945-0121-PN-CONV

 

Find Care, the doctor finder and transparency tool in Anthem Blue Cross and Blue Shield (Anthem)’s online directory, provides many Anthem members with the ability to search and compare cost and quality measures for in-network providers using the secure member portal at anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, name, or personalized match.

 

Beginning March 1, 2021, the personalized match sorting option will be available for searches by procedure type. This sorting option is based on algorithms which will use a combination of member and provider features to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions and demographics. Provider factors such as surgeon-facility pairing (an individual provider who performs a procedure at a specific facility), cost efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures.

 

These member and provider features will be combined to generate a unique ranking of surgeon-facility pairings or facility providers for each member conducting the procedure search. Surgeon-facility pairings with the highest overall ranking within the search radius will be displayed first with other pairings displayed in descending order based on overall rank and proximity to the center of the search radius.

 

The personalized match methodology for specialty-based searches remains unchanged. Members continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology has no impact on member benefits.

 

• Providers may review a copy of the new sorting methodology which has been posted on Availity -- our secure Web-based provider tool -- using the following navigation:  Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Provider Procedure Search Methodology.pdf.
• If you have general questions about the Find Care tool or this new sorting option, please contact Provider Customer Service.
• If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors, you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.

 

Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions.

 

 

924-0121-PN-NV

You no longer need to pick up the phone or head to the fax machine to check the status of an authorization request or update a case. Anthem Blue Cross and Blue Shield (Anthem) has added new features to Interactive Care Reviewer (ICR), our online medical and behavioral health authorization tool to improve your digital self-service experience.

 

• Do you need to update a case that was submitted by phone or fax? Now you can add clinical notes and make other updates to these authorization requests through ICR. To make the update you need to have the Authorization & Referral Request role assigned to you by your Availity Administrator.
  
  
  • To locate the case, log on to the Availity Portal and select Patient Registration | Authorizations & Referrals, then choose Auth/Referral Inquiry.
  • Search for the case in ICR by Member, Reference/Authorization Request Number, or by Date Range.
  • From the ICR Case Overview screen select Update Case to update service codes, provider information or clinical notes. If you only need to make changes or add to your notes, select Update Clinical. Select Submit Update to complete the request.

 

• We’ve removed the guesswork from the notes that are recommended for many standard authorization requests. ICR provides a check list of the supporting clinical information that will assist Anthem with completing the review. The list is located on the Clinical Details You can upload notes, images and photos directly through ICR. You can include the documentation immediately or you can submit your request then return to the case in ICR later and select Update Clinical to add the missing information.

 

• Check the status of a submitted case at a glance. The ICR UM tracker, located on the Case Overview screen provides a quick view of where the case is in the review process. You can view when Anthem received the request, when the clinical review is underway and completed and the final decision.

 

Additionally, we’ve added a new application to Payer Spaces – Chat with Payer that you can use to check the status of a submitted authorization request. This is a great option if you don’t have the role assignments required to access ICR and research a case. 

 

• To access the Chat with Payer application from Availity’s home page, select Payer Spaces | Chat with Payer.  Complete the form with the required information. You need to include the patient name, birth date and health plan member ID number. Choose Authorization Status as your topic for chat to conduct a live chat with a representative. 

 

 

922-0121-PN-CONV

You’re invited!

 

In this 60-minute webinar, you will learn how to use Availity's* Attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers.

We will explore new key workflow options to fit your organization’s needs, including how to:

 

• Work a request in the inbox of your Attachments Dashboard.
• Enter and submit a web claim including supporting documentation.
• Use EDI batch options to trigger a request in your inbox.
• Track attachments you submitted using sent and history lists in your Attachments Dashboard.
• Get set up to use these tools.

 

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

 

Register for an upcoming webinar session:

 

1. In the Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options:
   • In the Catalog, search by webinar title or keyword.
     • To find this specific live session quickly, use keyword medattach.
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you’ll receive emails with instructions to join the session.

 

Webinar Dates and Times (PT):

 

DATE	DAY	TIME (PT)
January 8, 2021	Friday	10:00 A.M. to 11:00 A.M.
January 19, 2021	Tuesday	12:00 P.M. to 1:00 P.M.

 

 

909-0121-PN-CONV

 

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

 

• Transition to AIM small joint guidelines
• Policy Update — Nurse Practitioner and Physician Assistant Services, Professional
• SNF admission reporting requirements for D-SNP plans
• Medicare Advantage Group Retiree Quick Reference Guide and FAQ

 

 

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ABSCRNU-0195-20

Effective January 1, 2021, Electrical Workers Local 357 in Nevada will offer a Medicare Preferred (PPO) plan from Anthem. Anthem will provide medical benefits for the Electrical Workers Local 357 retirees through Anthem’s Local Preferred Provider Organization (LPPO) product, which includes the National Access Plus benefit. This plan allows members to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.

 

Electrical Workers Local 357 member copays or coinsurance percentages will be the same whether their provider is in- or out-of-network. Locally or nationwide, doctors or hospitals — the member’s cost share doesn’t change.

 

Noncontracted providers may continue treating Electrical Workers Local 357 members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member cost share.

 

The Medicare Advantage plan offers the same hospital and medical benefits that original Medicare covers and also covers additional benefits that original Medicare does not, such as hearing, LiveHealth Online* and SilverSneakers.*

 

The prefix on the Medicare Advantage ID cards is AFJ.

 

Detailed prior authorization requirements are also available to contracted providers by accessing the Provider Self-Service Tool on the Availity Portal* at https://www.availity.com.

 

Providers will follow their normal claim filing procedures for Electrical Workers Local 357 member claims.

 

Providers may call Provider Services at 1-833-848-8730 for eligibility, prior authorization requirements and any questions about the Electrical Workers Local 357 member benefits or coverage.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross and Blue Shield.

 

 

ABSCRNU-0197-20

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare risk adjustment and documentation guidance (General):

• Series: Offered the first Wednesday of each month from 1:00 to 2:00 P.M. (ET)*
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity, Medicare risk adjustment and documentation guidance, from
  January 8, 2020 to December 2, 2020, has been reviewed and is acceptable for up to 1.00 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

To learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

https://bit.ly/2TYMgbn

* Note: Dates may be modified due to holiday scheduling

 

Medicare risk adjustment, documentation and coding guidance (Condition specific)

• Series: Offered the third Wednesday of each month from 1:00 to 2:00 P.M. (ET)
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity, Medicare risk adjustment documentation and coding guidance, from January 15, 2020 to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

 

For those interested in the following training topics, please register at the link below.

https://bit.ly/2IgxDO9

* Note: Enter the password provided, and the recording will play upon registration.

 

• Red flag HCCs
• Neoplasms
• Acute, chronic and status conditions
• Diabetes mellitus and other metabolic disorders
• Coinciding conditions in risk adjustment models

 

Please note that the original training events have been modified due to a transition within WebEx as of
August 1, 2020. The date and time of the events have not changed but the program link and invitation detail have been updated. Previously registered participants will need to re-register for a training event using the updated registration link(s) provided in this announcement.

 

 

ABSCRNU-0192-20

On August 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020. Visit Clinical Criteria to search for specific policies.

           

If you have questions or would like additional information, use this email.

 

 

ABSCRNU-0187-20

Please continue to check Medicaid Provider Communications & Updates at anthem.com/mediproviders for the latest Medicaid information.

 

• Transition to AIM small joint guidelines
• Updates to AIM Specialty Health Cardiac Clinical Appropriateness
• Medical Policies and Utilization Management Guidelines update
• InterQual October 2020 clinical criteria revisions
• Prior authorization requirements for Moderate to Deep Anesthesia for Dental Surgery in the Facility Setting

ANV-NU-0160-20

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ANVPEC-1409-20

HEDIS overview

The National Committee for Quality Assurance (NCQA) is a non-profit organization that accredits and certifies healthcare organizations. The NCQA establishes and maintains the Healthcare Effectiveness Data and Information Set (HEDIS^®). HEDIS is a tool comprised of standardized performance measures used to compare managed care plans. The overall goal is to measure the value of healthcare based on compliance with HEDIS measures. HEDIS also allows stakeholders to evaluate physicians based on healthcare value rather than cost. This article will outline specific changes to the HEDIS measures as outlined by the NCQA. The changes are effective for the measurement year (MY) 2020 to 2021. It is important to note that the state health agency has the authority to determine which measures and rates managed care organizations should capture.

 

HEDIS data helps calculate national performance statistics and benchmarks and sets standards for measures in NCQA Accreditation.

 

Health plans use HEDIS performance results to:

• Evaluate the quality of care and services.
• Evaluate provider performance.
• Develop performance improvement initiatives.
• Perform outreach to providers and members.
• Compare performance with other health plans.

 

HEDIS MY 2020 new measures:

• Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)
• Pharmacotherapy for Opioid Use Disorder (POD)
• Breast Cancer Screening (BCS-E)
• Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)
• Prenatal Depression Screening and Follow-Up (PND)
• Postpartum Depression Screening and Follow-Up (PDS)

 

HEDIS MY 2020 retired measures:

• Annual Monitoring for Patients on Persistent Medications (MPM)
• Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)
• Standardized Healthcare-Associated Infection Ratio (HAI)

 

Retired measures are no longer maintained by NCQA or included in the HEDIS measurement set. NCQA has determined that specific measures are clinically inappropriate and are no longer in use. Once retired, the measures are not used in any product, program or service, and all use must stop.

 

HEDIS MY 2020 revised hybrid measures:

• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
• Childhood Immunization Status (CIS)
• Immunizations for Adolescents (IMA)
• Cervical Cancer Screening (CCS)
• Colorectal Cancer Screening (COL)
• Care for Older Adults (COA)
• Controlling High Blood Pressure (CBP)
• Medication Reconciliation Post-Discharge (MRP)
• Transitions of Care (TRC)
• Prenatal and Postpartum Care (PPC)
• Well-Child Visits in the First 15 Months of Life (W15)
• Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
• Adolescent Well-Care Visits (AWC)

 

HEDIS MY 2020 revised administrative measures:

• Appropriate Testing for Children with Pharyngitis (CWP)
• Statin Therapy for Patient’s with Cardiovascular Disease (SPC)
• Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART)
• Osteoporosis Management in Women Who Had a Fracture (OMW)
• Follow-Up After Hospitalization for Mental Illness (FUH)
• Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
• Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)
• Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)

 

HEDIS and telehealth

HEDIS measures include synchronous telehealth (which requires real-time interactive audio and video telecommunications), telephone visits and online assessments, as appropriate. A measure specification will indicate when telephone visits or online assessments are eligible for use in reporting.

 

A measure specification that is silent about telehealth is assumed to include telehealth. Correct coding requires billing telehealth services using standard CPT^® and HCPCS codes for professional services in conjunction with a telehealth modifier and a telehealth POS code. Therefore, the CPT or HCPCS code in the value set will meet criteria (regardless of whether a telehealth modifier or POS code is present). A measure specification will indicate when telehealth is not eligible for use and is excluded.

 

The future of HEDIS

The future of HEDIS focuses on six core ideas:

• Allowable adjustments: New flexibility lets users modify measures without changing their clinical intent.
• Licensing and certification: Updated requirements ensure the accuracy of the results.
• Digital measures: HEDIS specifications that download directly into users’ data systems bring new ease of use.
• Electronic clinical data systems (ECDS): This new reporting method helps clinical data create insight for managing the health of individuals and groups.
• Schedule change: A new schedule gives users more time by providing the complete measure specifications sooner -- 11 months earlier than the traditional timeline.
• Telehealth: The access to care that telehealth has brought during COVID-19 is vital to quality now after the pandemic.

 

Resources:

HEDIS^® Measures and Technical Resources. https://www.ncqa.org/HEDIS^®/measures

 

 

ANV-NU-0179-20

Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) reviews the activities of the Food and Drug Administration’s (FDA) approval of drugs and biologics on a regular basis to understand the potential effects for our providers and members.

 

The FDA approves new drugs and biologics using various pathways. Recent studies on the effectiveness of drugs and biologics going through different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.

 

Here is a list of the approval pathways the FDA uses for drugs/biologics:

• Standard review — The standard review process follows well-established paths to make sure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public; watches for problems once drugs and biologics are available to the public; monitors drug/biologic information and advertising; and protects drug/biologic quality. Follow this link to learn more about the standard review process.

• Fast track — Fast track is a process designed to facilitate the development and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. Follow this link to learn more about the fast track process.
• Priority review — A priority review designation means FDA’s goal is to take action on an application within six months. Follow this link to learn more about the priority review process.
• Breakthrough therapy — This process is designed to expedite the development and review of drugs/biologics which may demonstrate substantial improvement over available therapy. Follow this link to learn more about the breakthrough therapy review process. 
• Orphan review — This refers to the review of drugs that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. Follow this link to learn more about the orphan drug review process. 
• Accelerated approval — These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. To learn more about the accelerated approval process, follow this link. 

 

New molecular entities approvals: January 2020 through August 2020

Certain drugs/biologics are classified as new molecular entities (NMEs) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.

 

Anthem reviews the FDA-approved NMEs on a regular basis. To facilitate the decision-making process, we are providing a list of NMEs approved from January to August 2020 along with the FDA approval pathway utilized.

 

Note: This information has no impact on our standard prior authorization/precertification process.

 

Generic name	Trade name	Standard review	Fast track	Priority	Break-through therapy	Orphan review	Accelerated approval	Approval date	Indication
Abametapir	Xeglyze	X						7/24/2020	Head lice
Amisulpride	Barhemys	X						2/26/2020	Postoperative nausea and vomiting
Avapritinib	Ayvakit		X	X	X	X		1/9/2020	PDGFRa exon 18 mutant gastrointestinal stromal tumor
Belantamab mafodotin	Blenrep			X	X	X	X	8/05/2020	Multiple myeloma
Bempedoic acid	Nexletol	X						2/21/2020	Dyslipidemia
Brexucabtagene autoleucel	Tecartus			X	X	X	X	7/24/2020	Mantle cell lymphoma
Capmatinib	Tabrecta			X	X	X	X	5/6/2020	Non-small cell lung cancer (NSCLC)
Decitabine/ cedazuridine	Inqovi			X		X		7/07/2020	Myelodysplastic syndromes
Eptinezumab-jjmr	Vyepti	X						2/21/2020	Migraine prevention
Fostemsavir	Rukobia		X	X	X			7/02/2020	Human immunodeficiency virus (HIV) treatment
Inebilizumab	Uplizna	X			X	X		6/11/2020	Neuromyelitis optica spectrum disorder
Isatuximab	Sarclisa	X				X		3/2/2020	Multiple myeloma
Lurbinectedin	Zepzelca			X		X	X	6/15/2020	NSCLC
Nifurtimox	Lampit			X		X	X	8/06/2020	Chagas disease
Oliceridine	Olinvyk	X	X					8/07/2020	Moderate to severe acute pain
Opicapone	Ongentys	X						4/24/2020	Parkinson’s disease
Osilodrostat	Isturisa	X				X		3/6/2020	Cushing’s disease
Ozanimod	Zeposia	X						3/25/2020	Multiple sclerosis
Peanut (Arachis hypogaea) allergen powder-dnfp	Palforzia	X	X		X			1/31/2020	Peanut allergy
Pemigatinib	Pemazyre			X	X	X	X	4/17/2020	Cholangiocarcinoma
Remimazolam	Byfavo	X						7/02/2020	Sedation for procedures
Rimegepant	Nurtec ODT			X				2/27/2020	Migraine treatment
Risdiplam	Evrysdi		X	X	X	X		8/07/2020	Spinal muscular atrophy
Ripretinib	Qinlock		X	X	X	X		5/15/2020	Gastrointestinal stromal tumor
Sacituzumab-hziy	Trodelvy		X	X	X	X	X	4/22/2020	Triple negative breast cancer
Selpercatinib	Retevmo			X	X	X	X	5/8/2020	NSCLC and thyroid cancers
Selumetinib	Koselugo		X	X	X	X		4/10/2020	Neurofibromatosis type 1
Tafasitamab	Monjuvi	X	X		X	X	X	7/31/2020	Large B-cell lymphoma
Tazemetostat	Tazverik			X		X	X	1/23/2020	Epithelioid sarcoma
Teprotumumab-trbw	Tepezza		X	X	X	X		1/21/2020	Thyroid eye disease
Triheptanoin	Dojolvi	X	X			X		6/30/2020	Long-chain fatty acid oxidation disorders
Tucatinib	Tukysa		X	X	X	X		4/17/2020	Breast cancer
Viltolarsen	Viltepso		X	X		X	X	8/12/2020	Duchenne muscular dystrophy

 

Source: www.fda.gov

 

 

ANV-NU-0175-20

On August 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Healthcare Solutions. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020. Visit Clinical Criteria to search for specific policies.

           

If you have questions or would like additional information, use this email.

 

 

ANV-NU-0173-20

Across the nation, too many women continue to experience pregnancy-related complications and death. More than 700 women die each year in the United States as a result of complications related to pregnancy or delivery.¹ Many of these deaths are preventable. In addition, significant racial and ethnic disparities exist in maternal morbidity and mortality. For example, Black/African American and American Indian/Alaska Native women are two to three times more likely to die from pregnancy-related complications compared to White women.² Anthem Blue Cross and Blue Shield Healthcare Solutions recognizes your role at the front lines of defense to support your diverse pregnant and postpartum patients. We want to ensure you have the right tools and resources to help your patients understand their risks and key maternal warning signs.

 

The Centers for Disease Control and Prevention (CDC) recently launched the Hear Her campaign to raise awareness of pregnancy-related complications, risks and death. The Hear Her campaign aims to increase knowledge of the symptoms women should seek medical attention for during pregnancy and in the year after delivery, such as vision changes and chest pain. Resources are available for pregnant and postpartum women, partners, families and friends, and health care providers.

 

The Hear Her campaign reminds us of the importance of listening to women. As a health care provider, you have an opportunity to listen to pregnant women, engage in an open conversation to make certain their concerns are adequately addressed, and help your patients understand urgent maternal warning signs. You can find more information on the CDC's Hear Her campaign at www.cdc.gov/hearher.

 

In addition, the Council on Patient Safety in Women's Health Care developed a tool to help women identify urgent maternal warning signs. The Urgent Maternal Warning Signs tool helps women recognize the symptoms they may experience during and after pregnancy that could indicate a life-threatening condition. The tool also provides additional information on the symptoms and conditions that place women at increased risk for pregnancy-related death. You can find the Council on Patient Safety in Women's Health Care Urgent Maternal Warning Signs tool at www.safehealthcareforeverywoman.org/urgentmaternalwarningsigns.

 

If you have a pregnant member in your care who would benefit from case management, please call us at 1‑844‑396-2330. Members can also call our 24/7 NurseLine at the number on their member ID card.

 

References

1    Centers for Disease Control and Prevention. (2020, August 13). Reproductive Health: Maternal Mortality. Retrieved from https://www.cdc.gov/reproductivehealth/maternal-mortality/index.html.

2    Centers for Disease Control and Prevention. (2019, September 5). Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths. Retrieved from https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html.

 

 

ANV-NU-0163-20

Anthem Blue Cross and Blue Shield Healthcare Solutions is now using the Notification Center on the Availity* Portal home page to communicate vital and time sensitive information. You will see a Take Action call out and a red flag in front of the message to make it easy to see new items requiring your attention.

 

Viewing the Notification Center updates should be included as part of your regular workflow so that you are aware of any outstanding action items.

 

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

 

 

ANV-NU-0159-20