Coverage guidelines effective November 1, 2018

Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following new and revised coverage guidelines effective November 1, 2018.  These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus (Medicaid), the Commonwealth Coordinated Care Plus (Anthem CCC Plus), Medicare Advantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).  Furthermore, the guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 3, 2018. 

SPECIAL NOTES:

The services addressed in ALL the coverage guidelines presented in this section and in the attachment under "Article Attachments" will require authorization for all of our products offered by HealthKeepers, Inc. with the exception of Anthem HealthKeepers Plus (Medicaid) and the Commonwealth Coordinated Care Plus (Anthem CCC Plus).  Other exceptions are Medicare Advantage and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).

A pre-determination can be requested for our Anthem PPO products.

Services related to specialty pharmacy drugs (non-cancer related) require a medical necessity review, which includes site of care criteria, as outlined in the applicable coverage or clinical UM guideline listed.

 

The following guidelines are addressed in the August 2018 edition of the Network Update (see attachment under "Article Attachments"):

 

• Eculizumab (Soliris®) (DRUG.00111)

 

• Lutetium Lu 177 dotatate (Lutathera®) (DRUG.00098)

 

• Epidermal Growth Factor Receptor (EGFR) Testing (GENE.00006)

 

• Recombinant Erythropoietin Products (CG-DRUG-05)

 

• White Blood Cell Growth Factors (CG-DRUG-16)

 

• Romidepsin (Istodax®) (CG-DRUG-51)

 

• Antihemophilic Factors and Clotting Factors (CG-DRUG-78)

• Adenoidectomy (CG-SURG-36)