February 1, 2025

February 2025 Provider Newsletter

Contents

AdministrativeCommercialMedicare AdvantageFebruary 1, 2025

New Communication Center added to Availity Essentials

AdministrativeCommercialFebruary 1, 2025

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Medical records needed for accurate payment of certain facility inpatient claims

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Hospice webinar

Education & TrainingCommercialMedicare AdvantageMedicaid Managed CareJanuary 1, 2025

Enhance billing and coding accuracy with new Payment Integrity training

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Medicaid provider orientation

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Behavioral health provider orientation

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Nursing facility webinar

Education & TrainingMedicaid Managed CareFebruary 1, 2025

Join our Provider Advisory Council

Policy UpdatesMedicaid Managed CareJanuary 28, 2025

Clinical Criteria updates

Reimbursement PoliciesCommercialFebruary 1, 2025

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Reimbursement policy update: Diagnostic Radiopharmaceuticals and Contrast MaterialsProfessional and Facility

Reimbursement PoliciesCommercialFebruary 1, 2025

New reimbursement policy: Place of Service — Professional

Federal Employee Program (FEP)CommercialFebruary 1, 2025

Corrected claim guidance for the Federal Employee Program®

Federal Employee Program (FEP)CommercialJanuary 14, 2025

Authorization for post‑acute care services for FEP members

PharmacyCommercialJanuary 27, 2025

Key formulary updates: effective January 1, 2025

PharmacyCommercialFebruary 1, 2025

Pharmacy information available on our provider website

PharmacyCommercialFebruary 1, 2025

Designated specialty pharmacy network updates

PharmacyMedicaid Managed CareJanuary 8, 2025

New specialty pharmacy medical step therapy requirements

Quality ManagementCommercialMedicare AdvantageFebruary 1, 2025

2025 Clinical Quality in Practice webinar series

Quality ManagementCommercialFebruary 1, 2025

Avoidance of Antibiotics Treatment for Acute Bronchitis/Bronchiolitis (AAB)

OHBCBS-CDCRCM-076707-25

AdministrativeCommercialJanuary 16, 2025

Submitting authorization for NICU services facilitates accurate and timely claims processing

As a crucial part of our commitment to providing the highest quality care and ensuring accuracy and timelines in the processing of claims, please remember to obtain prior authorization for neonatal intensive care unit (NICU) services at the level you intend to provide services.

Obtaining prior authorization helps us:

  • Ensure timely and appropriate care for our smallest and most vulnerable patients.
  • Streamline the claims process, thereby reducing delays and potential denials.
  • Facilitate accurate and efficient billing, which saves time and resources for everyone involved.

Please ensure all nonemergent NICU services are prior authorized before the commencement of treatment and continue to provide updates concurrently. This proactive step is essential for maintaining smooth and efficient operations. Prior authorization is not required for emergent NICU services or NICU services provided in the first 48 hours following birth for vaginal delivery and 96 hours following birth for cesarian delivery.

Should you have any questions or need further assistance with the authorization process, please do not hesitate to contact Provider Services via the number on the back of our member ID card.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-073281-24-CPN73119

AdministrativeCommercialMedicare AdvantageFebruary 1, 2025

New Communication Center added to Availity Essentials

In March, we will add new functionality to the provider enrollment and network management tool hosted on Availity Essentials to improve the correspondence experience. We will start posting letters related to your credentialing directly in the Communication Center and you will be able to download the correspondence as a PDF.

How will this help you:

  • Convenience — reduced time spent sorting through mailed documents
  • Faster access — no need to wait for mail service delivery
  • Ease of access — access your correspondence 24/7 digitally
  • Environmental benefits — saving paper and printing costs helps you and the planet

Before you begin

If your organization is not currently registered for Availity Essentials, the person in your organization designated as the Availity administrator should go to https://Availity.com and select Register. If you need assistance registering with Availity Essentials, visit https://Availity.com/Contact‑Us.

For organizations already using Availity Essentials, your administrator(s) will automatically be granted access to the provider enrollment tool.

Staff using the provider enrollment tool need to be granted the user role Provider Enrollment by an administrator. To find yours, go to My Account Dashboard >My Account > Organization(s) > Administrator Information.

At this time, Carelon Behavioral Health is out‑of-scope for this implementation.

Accessing the Communication Center

1. Log in to https://Availity.com.

2. Select your market.

3. Select Payer Spaces in the top menu.

4. Select the brand that corresponds to your market.

5. Accept the User Agreement (once every 365 days).

6. On the Applications tab, select Provider Enrollment and Network Management.

7. Select the Communication Center link under the My Communications option on the side menu.

8. Enter your TIN and NPI to access the letters.

Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CRCM-075626-24-CPN75180

AdministrativeMedicaid Managed CareJanuary 15, 2025

Updated billing guidance for hospice billing for nursing facility room and board (HCPC T2046) and ventilator/ventilator‑weaning services

Hospice nursing facility room and board (HCPC T2046)

Hospice providers billing for nursing facility room and board must submit claims using the HCFA (CMS-1500) form. The name of the nursing facility in which the services were delivered must be placed in Box 32, and the National Provider Identifier (NPI) related to the nursing facility must be placed in 32a.

Private room add‑on payment — effective for dates of service on or after December 18, 2024

If a hospice provider is billing for room and board in a skilled nursing facility (SNF), and the member was placed in a private room where the SNF is approved by ODM as a Category 1 or Category 2 private room service provider, the hospice provider is eligible for 95% of the Category 1 add‑on payment of $30 and of the Category 2 add‑on payment of $20 (as applicable).

Hospice providers should bill using the following code/modifier combinations to receive this add‑on payment. Category 1 and Category 2 should be billed on individual claim lines. Do not bill both modifiers on the same claim line.

Private room

Bill code

Modifier

95% of SNF add‑on

Category 1

T2046

XP

$28.50

Category 2

T2046

XU

$19.00

Example 1: Member transitioned from a Category 1 room to Category 2 room midmonth

Service type

Bill code

Modifier

Units billed

DOS

95% of SNF

Hospice care room and board

T2046

31

Jan. 1 to Jan. 31, 2025

$6,200

Private room, Category 1

T2046

XP

17

Jan. 1 to Jan. 17, 2025

$484.50

Private room, Category 2

T2046

XU

14

Jan. 18 to Jan. 31, 2025

$266

Example 2: Member remained in the Category 1 room for the entire month

Service type

Bill code

Modifier

Units billed

DOS

95% of SNF

Hospice care room and board

T2046

31

Jan. 1 to Jan. 31, 2025

$6,200

Private room, Category 1

T2046

XP

31

Jan. 1 to Jan. 31, 2025

$883.50

Example 3: Member remained in the Category 2 room for the entire month

Service Type

Bill Code

Modifier

Units billed

Dates of Service

95% of SNF

Hospice care room and board

T2046

31

Jan. 1 to Jan. 31, 2025

$6,200

Private room, Category 2

T2046

XU

31

Jan. 1 to Jan. 31, 2025

$589

Exceptions: SNFs that are receiving the enhanced ventilator rate are excluded from this program. If the SNF’s NPI is not recognized by ODM as having the appropriate specialty code of 86A (Category 1) and/or 86B (Category 2), the add‑on payment is subject to postpayment review/recoupment. These services are add‑on payments and will not be reimbursed if the nursing facility stay is not approved.

Hospice ventilator and ventilator‑weaning claims

Ventilator‑dependent and ventilator‑weaning (0410 and 0419) claims must be billed using the UB-04 institutional form.

Type of bill — 81X/081X: If the claim is billed with the incorrect type of bill, the claim will not be eligible for reimbursement.

When billing ventilator‑dependent and ventilator‑weaning claims, the hospice provider is required to include the name and NPI of the nursing facility in which the services were delivered in Box 80 (Remark code). In addition, when billing for ventilator and/or ventilator‑weaning services, the diagnosis code Z99.11 must be included.

Any claims for nursing facility room and board or ventilator/ventilator‑weaning that do not meet the instructions in this guidance may not be eligible for reimbursement and will require an adjusted claim submission. Nursing facility hospice (T2046) and ventilator/ventilator‑weaning services are not billable on the same date of service.

Note: The current list of facilities with Medicaid IDs (ohio.gov) can be found on the ODM website under Nursing Facility Rates. This information will allow claims to be properly priced and will avoid backend work and delay.

If you have any questions, write to ohmedicaidencpesupport@elevancehealth.com.

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-075577-24

AdministrativeCommercialFebruary 1, 2025

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Medical records needed for accurate payment of certain facility inpatient claims

To help ensure inpatient claims are processed quickly and accurately, and consistent with our Claims Requiring Additional Documentation reimbursement policy, starting May 1, 2025, inpatient claims with billed charges over $100,000, reimbursed partly or fully based on a percentage of charges, must include the full medical record upon submission. There is no impact to a member's ability to receive care.

The claim and medical record may be reviewed prior to claim payment or audited after claim payment. If claims meeting the above criteria are received without medical records, the claim will not be eligible for reimbursement until submitted with the appropriate documentation.

To view the full reimbursement policy, please visit our website: anthem.com/provider

Submit medical records with initial claim filing

Facilities can proactively submit medical records digitally with the initial claim filing via our preferred clearinghouse, Availity Essentials (https://Availity.com), through the Claim Status application. For additional options on claim and medical record submission, consult the provider manual at anthem.com/provider.

If your facility is not already registered for Availity Essentials or the Medical Attachments application, complete registration at https://Availity.com. Registering for the application allows facilities to receive digital notifications if documentation is required to complete a claim.

Training resources on submitting medical records attachments are available on our Digital Solutions Learning Hub. Trainings that begin with Attachments in the title provide education on this topic.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-075012-24-CPN74936

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Hospice webinar

Join us for an upcoming webinar.

The Ohio Medicaid Provider Relationship Account Management team will be giving an online presentation about hospice. Please join us to learn more about working with us and supporting your patients, our members.

Thursday, February 13, 2025 | 11 a.m. ET

Virtual presentation

Register

Sign up for the webinar here (medallia.com).

If you have questions

Contact your provider relationship management representative or email OhioMedicaidProvider@anthem.com.

Together, through genuine collaboration, we can continue to build our shared healthcare vision.

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-073585-24, OHBCBS-CD-073586-24

Education & TrainingCommercialMedicare AdvantageMedicaid Managed CareJanuary 1, 2025

Enhance billing and coding accuracy with new Payment Integrity training

We’re excited to introduce two new Payment Integrity trainings available on our Digital Solutions Learning Hub:

  • Payment Integrity: Emergency Dept Evaluation and Management Services
  • Payment Integrity: Outpatient Evaluation and Management Services

With an initial focus on these two key educational initiatives, our purpose is to amplify your billing and coding accuracy.

More trainings will be announced throughout the year.

Discover what our Digital Solutions Learning Hub has to offer.

Anthem Blue Cross and Blue Shield and Anthem Blue Cross and Blue Shield Medicaid are trade names of Community Insurance Company. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CDCRCM-075945-24-CPN75258, OHBCBS-CDCRCM-072257-24-CPN72085, OHBCBS-CDCRCM-077832-25-CPN77515, OHBCBS-CDCRCM-080181-25-CPN79720

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Medicaid provider orientation

Join our upcoming general provider orientation for Ohio Medicaid providers.

The Ohio Medicaid Provider Relationship Account Management team will host our next Provider Orientation in February. Please join us to learn more about working with us and supporting your patients, our members.

Wednesday, February 19, 2025 | 1 p.m. ET

Virtual presentation

Register

Sign up for the webinar here (medallia.com).

If you have questions

Contact your provider relationship management representative or email OhioMedicaidProvider@anthem.com.

Together, through genuine collaboration, we can continue to build our shared health vision.

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-073301-24, OHBCBS-CD-073302-24

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Behavioral health provider orientation

Join our upcoming orientation for behavioral health providers.

Please join us to learn more about working with us and supporting your patients, our members.

Tuesday, February 25, 2025 | 11 a.m. ET

Virtual presentation 

Register

Sign up for the webinar here (medallia.com).

If you have questions

Contact your provider relationship management representative or email OhioMedicaidProvider@anthem.com.

Through genuine collaboration, we can work to achieve improved outcomes in patients’ behavioral health.

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-073308-24, OHBCBS-CD-073310-24

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Nursing facility webinar

Join us for an upcoming webinar.

The Ohio Medicaid Provider Relationship Account Management team will be giving an online presentation for nursing facilities. Please join us to learn more about working with us and supporting your patients, our members.

Thursday, February 27, 2025 | 11 a.m. ET

Virtual presentation

Register

Sign up for the webinar here (medallia.com).

If you have questions

Contact your provider relationship management representative or email OhioMedicaidProvider@anthem.com.

We are committed to working with our care providers to improve outcomes in patients’ health.

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-073316-24, OHBCBS-CD-073318-24

Education & TrainingMedicaid Managed CareFebruary 1, 2025

Join our Provider Advisory Council

Anthem invites our Medicaid care providers in Ohio to participate in our Provider Advisory Council. The meeting’s intent is to collaborate with our provider community and gather input, discuss trends, identify challenges, and remove barriers — ultimately improving the healthcare delivery system.

If you are interested in participating, sign up by visiting the link below.

Provider Advisory Council sign-up (chkmkt.com)

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-074748-24

WebinarsMedicaid Managed CareJanuary 1, 2025

You are invited: Review the Value-Added Benefits and Social Determinants of Health program

Have questions or want to learn more about what Anthem has to offer our members?

Join us for a webinar led by Carmen Hallman, Ohio Medicaid Sales and Marketing Manager. She will review our Value-Added Benefits (VAB) and Social Determinants of Health (SDoH) program. By attending, you will gain knowledge and have additional guides and resources at your fingertips to assist your patients, our members.

Tuesday, March 11, 2025 | 1 p.m. ET

Virtual presentation 

Register

Sign up for the webinar here (medallia.com).

If you have questions

Contact your provider relationship management representative or email OhioMedicaidProvider@anthem.com.

We look forward to sharing resources and working with you to achieve improved outcomes for members in our communities.

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-074295-24, OHBCBS-CD-074296-24, OHBCBS-CD-074297-24

Policy UpdatesMedicaid Managed CareJanuary 28, 2025

Clinical Criteria updates

Effective March 1, 2025

Summary:

The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: newly published criteria
  • Revised: addition or removal of medical necessity requirements, new document number

Please share this notice with other members of your practice and office staff.

Please note:

  • The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective Date

Clinical Criteria Number

Clinical Criteria Title

New or Revised

March 1, 2025

CC-0267

Ebglyss (lebrikizumab-lbkz)

New

March 1, 2025

CC-0268

Lymphir (denileukin diftitox-cxdl)

New

March 1, 2025

CC-0269

Nemluvio (nemolizumab-ilto)

New

March 1, 2025

CC-0270

Niktimvo (axatilmab-csfr)

New

March 1, 2025

CC-0271

Tecelra (afamitresgene autoleucel)

New

March 1, 2025

CC-0011

Ocrevus (ocrelizumab)/ Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq)

Revised

March 1, 2025

CC-0012

Brineura (cerliponase alfa)

Revised

March 1, 2025

CC-0072

Vascular Endothelial Growth Factor (VEGF) Inhibitors

Revised

March 1, 2025

CC-0130

Imfinzi (durvalumab)

Revised

March 1, 2025

CC-0201

Rybrevant (amivantamab-ymjw)

Revised

March 1, 2025

CC-0250

Veopoz (pozelimab-bbfg)

Revised

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-073588-24

Reimbursement PoliciesCommercialFebruary 1, 2025

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Reimbursement policy update: Diagnostic Radiopharmaceuticals and Contrast MaterialsProfessional and Facility

Beginning with dates of service on or after May 1, 2025, Anthem will update the Diagnostic Radiopharmaceuticals and Contrast Materials — Professional and Facility reimbursement policy to remove the code list located in the Related Coding section. Providers should continue to follow the policy guidelines that identify the services eligible for reimbursement. Providers can refer to the AMA CPT Manual or HCPCS Level II Manual for correct coding. 

For specific policy details, visit the reimbursement policy page.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-075363-24

Reimbursement PoliciesCommercialFebruary 1, 2025

New reimbursement policy: Place of Service — Professional

As of December 10, 2024, we retired the reimbursement policies titled Office Place of Service — Professional C‑13004 and Place of Service — Professional C‑09001. These policies have been combined to create a new reimbursement policy titled Place of Service — Professional C‑24004.

Under this policy, we require the appropriate place of service code to be billed on a CMS‑1500 claim form to be eligible for reimbursement. The place of service is determined by the following:

  • CPT® or HCPCS Level II code description
  • CPT coding guidelines

For specific policy details, visit the reimbursement policies page at https://tinyurl.com/yhwxzk69.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-076129-24-CPN75910

Federal Employee Program (FEP)CommercialFebruary 1, 2025

Corrected claim guidance for the Federal Employee Program®

Our digital first approach enables providers to submit EDI corrected claims through Availity Essentials or the electronic data interchange (EDI).

Corrected claim guidance

When submitting a corrected claim, include all previous information along with any corrections or additions.

To correct a claim billed to us in error, submit the entire claim as a void/cancel. A new claim may be required if we identify missing or incorrect information based on the guidelines in the Claims Submission section. Providers will receive written or electronic notification indicating the missing data.

The provider manual at https://tinyurl.com/43aep5uf offers guidance on submitting corrected claims, helping to prevent issues with reimbursement.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-075755-24

Federal Employee Program (FEP)CommercialJanuary 14, 2025

Authorization for post‑acute care services for FEP members

For services beginning on January 1, 2025, prior authorization requests for admission to or concurrent stay requests in an inpatient acute rehab facility (ARF) or long‑term acute care hospital (LTACH) will be handled by the FEP Case Management team to review for medical necessity and care coordination. This change impacts members of the Anthem Blue Cross and Blue Shield Federal Employee Program® (FEP®), including Federal Employee Health Benefit (FEHB) and Postal Service Health Benefit (PSHB), The FEP Case Management team may be contacted by phone at 800‑711-2225 for FEHB members or 833‑277-5220 for PSHB members. Clinical information should be faxed to 866‑862-4288.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-074100-24

PharmacyCommercialJanuary 27, 2025

Key formulary updates: effective January 1, 2025

Effective with dates of service on and after January 1, 2025, and in accordance with the CarelonRx, Inc. pharmacy and therapeutics (P&T) process, we updated our drug lists that support commercial health plans. Updates include changes to drug tiers and the removal of medications from the formulary.

Please see the attachment here for more information.

CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-075572-24-CPN75351

ATTACHMENTS (available on web): Key formulary updates: effective January 1, 2025_Blue Cross Blue Shield (pdf - 0.19mb)

PharmacyCommercialFebruary 1, 2025

Pharmacy information available on our provider website

Visit the Drug List page on our website for more information about:

  • Copayment/coinsurance requirements and their applicable drug classes.
  • Drug lists and changes.
  • Prior authorization criteria.
  • Procedures for generic substitution.
  • Therapeutic interchange.
  • Step therapy or other management methods subject to prescribing decisions.
  • Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy‑related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing the administrative burden because we value you, our care provider partner.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-076188-24

PharmacyCommercialFebruary 1, 2025

Designated specialty pharmacy network updates

Anthem requires providers to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through our contracted medical specialty pharmacies.

Updates

Effective for dates of service on and after April 1, 2025, the HCPCS code J2796 for Nplate (romiplostim), which is presently on the Designated Medical Specialty Pharmacy Drug List, will be replaced with J2802.

Additionally, effective for dates of service on and after April 1, 2025, the following specialty pharmacy medications will be removed from the Designated Medical Specialty Pharmacy Drug List and will no longer need to be obtained from our contracted medical specialty pharmacy:

HCPCS

Description

Brand name

J1950

INJ LEUPROLIDE ACETATE PER 3.75 MG

LUPRON DEPOT

J9217

LEUPROLIDE ACETATE 7.5 MG

ELIGARD/LUPRON DEPOT

J9218

LEUPROLIDE ACETATE, PER 1 MG

LUPRON

To access the current Designated Medical Specialty Pharmacy Drug List, please visit anthem.com/provider, select Providers, select Forms and Guides (under the Provider Resources column), select Ohio, scroll down, and select Pharmacy in the Category dropdown. The Designated Medical Specialty Pharmacy Drug List may be updated periodically by Anthem.

If you have questions or would like to discuss the terms and conditions to be included as a designated specialty pharmacy network provider, please contact your contract manager with Anthem. Thank you for your continued participation in the Anthem networks and the services you provide to our members. We are committed to a future of shared success.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CM-075000-24

PharmacyMedicaid Managed CareJanuary 7, 2025

Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on or after March 1, 2025, the following medication codes will require prior authorization.

Please note, inclusion of a national drug code (NDC) on your medical claim is necessary for claims processing.

Visit the Clinical Criteria to search for the specific Clinical Criteria listed below.

Clinical Criteria

HCPCS or CPT® code(s)

Drug name

CC‑0265

J0175

Kisunla (donanemab)

CC‑0041

J3590

Piasky (crovalimab‑akkz)

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 844‑912-1226.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-072634-24-CPN72396

PharmacyMedicaid Managed CareJanuary 8, 2025

New specialty pharmacy medical step therapy requirements

Effective on March 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. Step therapy review will apply upon prior authorization initiation or renewal, in addition to the current medical necessity review of all drugs noted below.

The list of Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.

Clinical Criteria

Status

Drug(s)

HCPCS codes

CC‑0078

Non‑Preferred

Orencia

J0129

CC‑0078

Preferred

Avsola

Q5121

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-075162-24-CPN72295

Quality ManagementCommercialMedicare AdvantageFebruary 1, 2025

2025 Clinical Quality in Practice webinar series

We are excited to announce our 2025 Clinical Quality in Practice, a continuing education webinar series. This comprehensive series will cover a diverse range of critical topics designed to equip clinicians with the latest strategies and best practices in patient care.

The webinar series will explore essential areas, such as:

  • Clinical strategies to care for patients with diabetes.
  • Clinical strategies to care for patients with cardiovascular disease and hypertension.
  • Post acute care management.
  • Motivating patients to adhere to cancer prevention and screenings.
  • Clinical strategies to increase flu vaccinations.
  • Clinical strategies for screening and preventive care.
  • Enhancing coordination of care.

Participants will have the opportunity to engage with experienced practitioners and thought leaders, gaining valuable insights that can be immediately applied in clinical settings.

For a detailed schedule of live events and a full listing of available on‑demand webinars that you can start viewing now, visit our Engagement Hub. Don’t miss this chance to advance your clinical expertise and enhance patient outcomes.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CRCM-075332-24-CPN74850

Quality ManagementCommercialFebruary 1, 2025

Avoidance of Antibiotics Treatment for Acute Bronchitis/Bronchiolitis (AAB)

The National Committee Quality Assurance (NCQA) develops and collects Healthcare Effectiveness Data and Information Set (HEDIS®) measurements to set performance and drive improvement in quality‑of-care outcomes. The AAB measure is one of the priority measures that have many opportunities to optimize antibiotic prescribing.

The Federal Employee Program (FEP) is continuously working toward improving clinical quality of care and performance outcomes. To improve HEDIS AAB compliance, the FEP takes this opportunity to ask for your commitment to promote the appropriate use of antibiotic prescription in protecting your patients from harmful side effects and possible resistance to antibiotics over time.

According to the CDC, in U.S. doctors’ offices and emergency departments, at least 28% of antibiotic prescriptions each year are unnecessary, and an estimated 80 to 90% of antibiotic prescriptions occur in the outpatient setting, which makes improving antibiotic prescribing and use a national priority. The national guidelines recommend against prescribing antibiotics bronchitis/bronchiolitis for healthy people.

What is the HEDIS AAB measure?

The AAB measure looks at the percentage of episodes for members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.

If a patient is diagnosed with an acute bronchitis/acute bronchiolitis and medically requires an antibiotic prescription due to comorbid conditions at the time of the visit, it is important to document the comorbid conditions/diagnosis by using the appropriate ICD‑10-CM on the same visit claim which will remove the patient from the HEDIS AAB measure.

The table below lists the common ICD‑10-CM diagnosis codes for outpatient visits that trigger patients to be included in the HEDIS AAB measure:

Code

Description

J20.3, J20.4, J20.5, J20.6, J20.7, J20.8, J20.9

Acute bronchitis

J21.x, J21.0, J21.1, J21.8, J21.9

Acute bronchiolitis

Common ICD‑10-CM codes that exclude patients from the HEDIS AAB measure are:

Code

Description

J02.x

Acute pharyngitis

J03.x

Acute tonsillitis

H66.xxx

Suppurative otitis media

J01.xx

Acute sinusitis

J18.xx

Pneumonia

J32.xx

Chronic sinusitis

J35.xx

Chronic tonsillitis; hypertrophy tonsils

J39.x

Disease upper respiratory tract

L03.xx

Cellulitis/acute lymphangitis

N39.xx

UTI

Note: These lists are not all‑inclusive. This information is not about a change in policy but a reference to quality improvement activities.

The CDC is an excellent source for antibiotic information and awareness. In fact, the CDC leads in the Antibiotics Stewardship Training. We encourage you to take advantage of these continuing education opportunities:

Helpful tips:

  • If a patient insists on an antibiotic:
    • Refer to the illness as a chest cold rather than bronchitis; patients tend to associate the label with a less‑frequent need for antibiotics.
    • Write a prescription for symptom relief, such as an over‑the-counter medicine.
    • Reiterate the CDC’s recommendation that antibiotics do not work against viruses that cause most chest colds or bronchitis.
    • Treat with antibiotics if the patient has a competing diagnosis listed above.
  • Document accurately and use the correct ICD‑10-CM diagnosis codes.
  • Use correct exclusion codes when appropriate.
  • Maintain timely submission of claims and encounter data.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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