Provider News OhioFebruary 2019 Anthem Ohio Provider NewsletterMaterial Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.
- Medical Policy/Clinical Guidelines Updates – February 2019*
- Reimbursement Policy Updates – February 2019*
- Clinical criteria updates for specialty pharmacy*
- Specialty pharmacy prior authorization list expansion*
- Specialty pharmacy medical step therapy drug list expansion*
- Professional billing - Update regarding E/M with modifier 25
- Medicare and Medicaid updates
Anthem Blue Cross and Blue Shield would like to remind you of the procedures to follow for inpatient claim denials.
If your inpatient claim is denied in full, your next steps will depend on the reason for the denial.
- Late Authorizations/No Authorizations If your UM letter states a 30% penalty should apply and you received a 100% denial, contact Anthem to dispute the underpayment.
- Inappropriate Setting/Inappropriate Level of Care: If your UM letter states a 30% penalty should apply and you received a 100% denial, contact Anthem to dispute the underpayment.
- Not Medically Necessary (NMN): Provider can appeal NMN denial until appeal options are exhausted. Member is held harmless.
For any of these denial reasons, it is inappropriate to re-bill an outpatient claim for ancillary services rendered in the inpatient setting for commercial polices. This includes but is not limited to Emergency Department, Imaging, Laboratory services, Specialty Pharmacy, Surgeries.
Claims should be coded and billed based on the medical record and the physician order.
If claim is billed as Inpatient bill type in error:
- A frequency type 8 (void) of the Inpatient claim must be received first by the provider, or in conjunction with a frequency type 1 (original) outpatient claim before the outpatient bill type claim will be processed. This can be done electronically or with a PAR (Provider Adjustment Request) Form. Further instructions are in the Ohio provider manual.
For complete information on electronic claims processing procedures, visit our EDI website.
This update does not apply to Medicare and Medicaid.
One of the measures Anthem Blue Cross and Blue Shield (Anthem) reports on is the Controlling High Blood Pressure (CBP) measure. This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mm Hg) during the measurement year (2018).
What’s new for 2019?
- The Controlling High Blood Pressure (CBP) measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
- If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
- Compliant BP is defined as <140/90 mm Hg for all members.
- Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the Provider can be utilized for the measure.
What do we need from you?
We need the last 2 office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018 please send that documentation as well.
Common chart deficiencies:
- Recheck elevated blood pressures readings and document all BP readings in the medical record.
For more information on HEDIS visit the Anthem Provider Portal online at Anthem.com. Click on Providers > Click Polices and Guidelines > Select your State>Scroll down and click View Med Policies and UM Guideline >Click Health & Wellness > Scroll down to Quality Improvement and Standards> and then scroll down on the page to HEDIS Information.
Thank you for your continued cooperation and support of HEDIS.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on November 8, 2018 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
New Medical Policy
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Effective May 1, 2019
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MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
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The measurement of exhaled nitric oxide is considered INV&NMN in the diagnosis and monitoring of asthma and other respiratory disorders
· The measurement of exhaled breath condensate is considered INV&NMN in the diagnosis and monitoring of asthma and other respiratory disorders
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The below current Clinical Guidelines and/or Medical policies were reviewed and updates were approved
*requires precertification
Title
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Change
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Effective date
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CG-BEH-01 Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
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• Added tests for metabolic markers in the blood, urine, tissue, or other biologic materials (also known as metabolomics), including but not limited to Amino Acid Dysregulation Metabotype (ADDM) testing as NMN
- Added existing CPT PLA code 0063U (NMN); added new CPT psych testing codes 96112, 96113, 96121, 96130-96133, 96136-96139, 96146 replacing 96101-96103, 96111, 96118-96120 & new CPT 81171, 88172 for AFF2 gene replacing Tier 2 eff 01/01/19
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5/1/2019
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CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
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• Content moved from MED.00100
• No change to clinical indications
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1/3/2019
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CG-MED-80 Positron Emission Tomography (PET) and PET/CT Fusion*
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• Content moved from RAD.00002
• No change to clinical indications
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1/3/2019
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CG-SURG-27 Sex Reassignment Surgery*
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• Added criteria requiring referral letters to mastectomy MN statement
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5/1/2018
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Effective with dates of service on or after May 1, 2019, Anthem Blue Cross and Blue Shield will require review of the below 2 Clinical Guidelines for medical necessity. Medical necessity review will require preauthorization. Ordering and servicing providers may submit prior authorization requests by contacting the phone number on the back of the members ID card.
Clinical Guideline Name
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Description
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CG-SURG-49: Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
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This document addresses the use of peripheral vascular angioplasty, with and without stenting, and with or without atherectomy, for the treatment of occlusive peripheral arterial disease (PAD) of the lower extremities.
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CG-SURG-55: Intracardiac Electrophysiological Studies and Catheter Ablation
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This document addresses two intracardiac electrophysiological procedures and studies, including electrophysiological studies (EPS) and catheter ablation. EPS with programmed ventricular stimulation (PVS) is used, as a complement to a full workup, to document the inducibility and type of induced arrhythmia, (for example, atrial fibrillation, ventricular tachycardia, etc.); also to assess the risks for recurrent ventricular tachycardia or sudden cardiac death; to evaluate symptoms, such as syncope; and to guide catheter ablation procedures in selected individuals when arrhythmias are suspected to be the etiology. EPS is also used, in appropriate individuals, for the purpose of assessment for eligibility for treatments, such as implantable cardioverter defibrillator therapy.
Transcatheter or intracardiac catheter ablation is a treatment option for individuals with certain types of arrhythmias and is performed following imaging and electro-anatomic mapping, which is done during EPS to identify the specific location of the ectopic excitable foci. Catheter ablation utilizes radiofrequency or cryoablation energy to eradicate or ablate the arrhythmogenic foci in the heart which is the source of the arrhythmia. In this way, catheter ablation reduces or prevents recurrent episodes of certain supraventricular and ventricular arrhythmias that have demonstrated therapeutic response to this treatment modality in clinical practice.
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Anthem’s Medical Polices and Clinical UM Guidelines are available online on Anthem’s website at Anthem.com. Select Providers > Select your State > Select Review Policies > Select View Policies and Guidelines > Select Medical Policies and Clinical UM Guidelines (for Local Plan members).
Effective for dates of service on and after May 18, 2019, the following updates will apply to the AIM Specialty Health Musculoskeletal Program Clinical Appropriateness Guidelines.
Spine Surgery – Enhancements as indicated by section below:
- General Requirements
- Reporting of symptom severity: expanded to include IADLs as functional impairment
- Tobacco Cessation: removed nicotine-free documentation requirement
- Cervical Decompression with or without Fusion
- Added exclusion of cervical/thoracic laminectomy if criteria not met
- Lumbar Discectomy, Foraminotomy, and Laminotomy
- Added criteria to define radicular pain for Lumbar herniated intervertebral disc
- Lumbar Fusion and Treatment of Spinal Deformity (including scoliosis and Kyphosis)
- Added indication and criteria for Flat back Deformity
- Added criteria for Isthmic spondylolisthesis
- Added indication and criteria for Scheuermann’s Kyphosis
- Lumbar Laminectomy
- Added exclusion of lumbar laminectomy if criteria not met
- Noninvasive Electrical Bone Growth Stimulation
- Added risk factor criteria for cervical non-invasive bone growth stimulation
Interventional Pain Guidelines – Enhancements as indicated by section below:
- General Requirements
- Reporting of symptom severity: expanded to include IADLs as functional impairment
- Therapeutic Epidural Steroid Injection
- Updated time period of initial advanced imaging
- Definition and frequency of repeat therapeutic epidural steroid injection
- Updated maximum number of annual injections
- Added criteria for subsequent injection after suboptimal initial response
- Paravertebral Facet Injection/Nerve Block/Neurolysis
- Updated injection frequency limitations
- Diagnostic Intraarticular Sacroiliac Joint Injections
- Updated pain reduction from initial injection
- Spinal Cord Stimulators
- Added criteria for revision/removal of spinal cord stimulator
- Separated criteria of trial stimulation and permanent stimulator implantation
- Added exclusion of dorsal root ganglion stimulation
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: Central: 800-554-0580, Monday – Friday, 8:30 a.m. – 7:00 p.m. ET.
Please note, this program does not apply to FEP or National Accounts.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.
Update regarding E/M with modifier 25: Same day as procedure when a prior E/M for the same or similar service has occurred - Professional
Anthem Blue Cross and Blue Shield (Anthem) has identified that providers often bill a duplicate Evaluation and Management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Anthem’s policy on use of modifier 25.
Beginning with claims processed on or after March 1, 2019, Anthem may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.
If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant, and separately identifiable E/M service, please submit those medical records for consideration.
Body Mass Index (BMI) – Facility
Beginning with dates of service on or after May 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) is updating the facility Body Mass Index (BMI) Reimbursement Policy. Reimbursement will be based on a review of all comorbidities, diagnosis codes reported, and the facility specific reimbursement methodology for Body Mass Index (BMI) diagnosis codes reported as a secondary clinical condition along with other criteria set forth in our policy.
For additional information, please review our updated policy dated May 1, 2019 by visiting the Facilities Reimbursement Policy page for your state on anthem.com/provider.
Indiana Reimbursement Policies-Facility; Kentucky Reimbursement Policies-Facility; Missouri Reimbursement Policies-Facility; Ohio Reimbursement Policies-Facility; Wisconsin Reimbursement Policies-Facility
Reminder: Review ICD-10-CM Coding Guidelines – Professional
To help ensure the accurate processing of submitted claims, keep in mind ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for patient encounters. Remember ICD-10-CM has two different types of excludes notes and each type has a different definition. In particular, one of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 Notes. An Excludes 1 Note is used to indicate when two conditions cannot occur together (Congenital form versus an acquired form of the same condition). An Excludes 1 Note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes 1 Note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note applies to all codes in the section.
Beginning with dates of service on or after May 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) is updating our Injectable Substances with Related Injection Services reimbursement policy. The update will reflect that when a claim for an injection service is submitted without the applicable Healthcare Common Procedure Coding System (HCPCS Level II) drug or injectable substance code for the injected drug or substance, the code for the injection service will not be eligible for reimbursement.
Additionally, when submitting a claim for an aspiration service, with or without an injection, be sure to include code J3590 (unclassified biologics) with a zero charge to indicate the biologic contents of the syringe after aspiration, or the service will not be eligible for reimbursement.
For additional information, review our updated policy dated May 1, 2019 by visiting the Professional Reimbursement Policy page for your state at anthem.com/provider.
Indiana Reimbursement Policies-Professional ; Kentucky Reimbursement Policies-Professional; Missouri Reimbursement Policies-Professional; Ohio Reimbursement Policies-Professional; Wisconsin Reimbursement Policies-Professional
Centauri Health Solutions is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program. We value the relationship with our providers, and ask that you respond to the requests in support of risk adjustment, HEDIS and other government required activities within the requested timeframe. Centauri Health will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary). We ask that you please promptly comply within five (5) business days of the record requests. If you have any questions, please contact Catherine Carmichael with Blue Cross Blue Shield Federal Employee Program at (202) 942-1173 or Carol Oravec with Centauri at (440) 793-7727.
The following clinical criteria will be effective May 1, 2019.
Erythropoiesis Stimulating Agents ING-CC-0001
Clinical criteria ING-CC-0001 addresses the use of recombinant erythropoietin products, also known as erythropoiesis stimulating agents (ESAs), for the treatment of severe anemia in chronic kidney disease (CKD), HIV, cancer, surgery, and other conditions.
Effective for dates of service on and after May 1, 2019, the use of Procrit®, Epogen®, and Retacrit™ for the treatment of severe anemia in hepatitis C, chronic inflammatory disease, and bone marrow transplant are considered not medically necessary.
H.P. Acthar Gel® (repository corticotropin injection) ING-CC-0004
Clinical criteria ING-CC-0004 addresses the use of repository corticotropin injection for the treatment of infantile spasms (West syndrome) and adults with a corticosteroid-responsive condition, including but not limited to acute exacerbations of multiple sclerosis.
Effective for dates of service on and after May 1, 2019, repository corticotropin injections for the treatment of conditions other than infantile spasms (West syndrome) are considered not medically necessary.
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists ING-CC-0072
Clinical criteria ING-CC-0072 addresses the use of intravitreal vascular endothelial growth factor (VEGF) antagonists for the treatment of diabetic retinopathy and other retinal disorders associated with neovascularization.
Effective for dates of service on and after May 1, 2019, the use of Eylea® for the treatment of radiation retinopathy is considered not medically necessary.
To access the clinical criteria information please visit our Clinical Criteria website.
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new clinical criteria or current clinical guideline will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
To access the clinical criteria information, please visit our Clinical Criteria website.
Clinical Criteria/Guideline
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HCPCS or CPT Code
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NDC Code
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Drug
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CG-DRUG-63
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J3490
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68152-0112-01
68152-0114-01
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Khapzory™
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ING-CC-0002
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Q5110
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00069-0291-10
00069-0291-01
00069-0292-01
00069-0292-10
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Nivestym™
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ING-CC-0002
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J3490
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68152-0112-01
68152-0114-01
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Udenyca™
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ING-CC-0003
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J1599
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68982-0820-01
68982-0820-02
68982-0820-03
68982-0820-04
68982-0820-05
68982-0820-06
68982-0820-81
68982-0820-82
68982-0820-83
68982-0820-84
68982-0820-85
68982-0820-86
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Panzyga®
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ING-CC-0034
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J3590
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47783-0644-01
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Takhzyro®
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ING-CC-0062
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J3590
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61314-0871-02
61314-0871-06
61314-0876-02
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Hyrimoz™
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ING-CC-0062
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Q5109
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00069-0811-01
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Ixifi™
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ING-CC-0065
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J7192
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00026-3942-25
00026-3944-25
00026-3946-25
00026-3948-25
00026-4942-01
00026-4944-01
00026-4946-01
00026-4948-01
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Jivi®
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ING-CC-0074
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J8655
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69639-0102-01
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Akynzeo®
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ING-CC-0077
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C9399
J3590
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68135-0058-90
68135-0673-40
68135-0673-45
68135-0756-20
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Palynziq™
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ING-CC-0081
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J0584
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69794-0102-01
69794-0203-01
69794-0304-01
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Crysvita®
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ING-CC-0082
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C9399
J3490
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71336-1000-01
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Onpattro™
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The following clinical criteria will be effective May 1, 2019.
Colony Stimulating Factor Agents ING-CC-0002
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Additional information regarding biosimilar drugs can be found by viewing the reference document, Biosimilar Drugs – What are they? here.
To access the clinical criteria information please visit our Clinical Criteria website.
Clinical Criteria
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Status
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Drug
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HCPCS or CPT Code
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NDC Code
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ING-CC-0002
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Preferred Agent
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Zarxio®
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Q5101
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61314-0304-01
61314-0304-10
61314-0312-01
61314-0312-10
61314-0318-01
61314-0318-10
61314-0326-01
61314-0326-10
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ING-CC-0002
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Non-Preferred Agent
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Neupogen®
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J1442
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55513-0530-01
55513-0530-10
55513-0546-01
55513-0546-10
55513-0924-01
55513-0924-10
55513-0924-91
55513-0209-01
55513-0209-10
55513-0209-91
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ING-CC-0002
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Non-Preferred Agent
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Granix®
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J1447
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63459-0910-11
63459-0910-12
63459-0910-15
63459-0910-17
63459-0910-36
63459-0912-11
63459-0912-12
63459-0912-15
63459-0912-17
63459-0912-36
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ING-CC-0002
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Non-Preferred Agent
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Nivestym™
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Q5110
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00069-0291-10
00069-0291-01
00069-0292-01
00069-0292-10
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Visit anthem.com/pharmacyinformation 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, and any other requirements, restrictions, or limitations that apply to using certain drugs.
The commercial drug list is posted to the web site quarterly (the first of the month for January, April, July and October).
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. AllianceRX Walgreens Prime is the specialty pharmacy program for the FEP. You can view the 2018 Specialty Drug List or call us at 888-346-3731 for more information.
Anthem Blue Cross and Blue Shield (Anthem) is required to follow all clinical and reimbursement policies established by Original Medicare in the processing of claims and determining benefits. Anthem follows all Original Medicare local coverage determinations, national coverage determinations, Medicare rulings, code editing logic and the Social Security Act.
Anthem may offer additional benefits that are not covered under Original Medicare. Certain benefits are only covered when provided by a vendor selected by Anthem. More information can be found at anthem.com/medicareprovider. You may also contact Provider Services at the phone number on the back of the member ID card.
AIM Specialty Health ® groups CPT codes on authorizations so they can be reviewed together to support a procedure or therapy. Grouped codes are used for radiology, cardiology, and sleep and radiation therapy programs. The groupings can be found at http://aimspecialtyhealth.com/ClinicalGuidelines.html by selecting the appropriate solution and then the exam or therapy being performed. Additional information is available at anthem.com/medicareprovider under Important Medicare Advantage Updates.
Refractions and routine eye exams are not covered under medical insurance for Anthem members. These benefits may be available through the member’s supplemental insurance. These services must be billed to the supplemental vendor. Check your patient’s Anthem ID card for the name of the vendor.
Additional information, including billing modifiers and documentation requirements, will be available at anthem.com/medicareprovider under Important Medicare Advantage Updates.
Effective for dates of service beginning January 1, 2019, the following Medicare Part B devices will be preferred to support cost-effective benefits. During precertification initiation or renewal, providers requesting a nonpreferred device will be encouraged to switch to a preferred product. The preferred and nonpreferred products are listed below.
Preferred devices
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Nonpreferred devices
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Euflexxa® (J7323)
Hyalgan®/Supartz®/Visco-3® (J7321)
Durolane® (J7318)
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Gel-One® (J7326)
Gelsyn-3® (J7328)
Genvisc 850® (J7320)
Hymovis® (J7322)
MonoviscTM (J7327)
Orthovisc® (J7324)
Synvisc® or Synvisc-One® (J7325)
TriviscTM (J7329)
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