Obtain precertification when Pre‑Payment Review program applies

Precertification (prior authorization) is required for items and criteria referenced in this document for applicable local fully‑insured Anthem Blue Cross members and select ASO members when services are medically managed as part of a purchased program; providers will be notified upon requesting precertification if it is required for the member.

• If the Pre‑Payment Review Program has not been purchased by the account, precertification is not required and clinical review will not be performed.

Reference indexed CG entries when requesting authorization

The document indexes numerous Clinical Guideline (CG) entries and associated CG numbers that typically correspond to prior authorization policies; providers should reference the listed CG numbers when preparing authorization requests.

• Examples of indexed CG entries appear throughout the listing (e.g., CC‑0174, CC‑0175, CC‑0187–CC‑0197, CC‑0200–CC‑0264).

Use drug‑specific CGs to determine PA criteria

Drug‑specific Clinical Guidelines (CG numbers and titles) listed in this document are the governing references used to determine precertification/prior authorization requirements for the named specialty drugs under California PPO plans.

• Providers must use the drug‑specific CG title/number (as listed) to locate the detailed prior authorization criteria in the corresponding guideline document.

Listed drug‑specific guidelines imply PA — consult each CG

This fragment lists many drug‑specific CG titles and CG numbers (drug‑specific guideline entries) for California PPO; while the listing implies prior authorization, this extract does not include the explicit submission requirements or affected billing codes — providers must consult the individual CG for those details.

• Listed examples include Danyelza (naxitamab‑gqgk), Oxlumo (lumasiran), Margenza (margetuximab‑cmkb), Breyanzi (lisocabtagene maraleucel).

Include CG number(s) on PA requests

When submitting authorization requests, reference the CG number(s) provided in the index (e.g., CG‑MED‑19, CG‑MED‑34, CG‑SURG‑92 and many CC‑/CG‑ prefixed numbers) so the plan can apply the correct guideline during review.

• Carelon Clinical Appropriateness guidelines are also cited with web links for specialty topics (cardiology, genetic testing, radiology, surgical site‑of‑care) and should be referenced when noted.

PA required for select accounts — provider will be notified

Prior authorization review applies for select accounts using the Anthem Clinical UM Guideline and for certain Carelon guidelines; providers will be notified when requesting precertification if prior authorization is required for the member.

• Applicability is limited to local fully‑insured and select ASO members when the employer/account has purchased the program.

Check individual CGs for step therapy rules

Many listed guideline entries may contain step therapy rules within their full guideline documents; this index does not enumerate those rules, so providers must review the individual CG for any step therapy requirements.

• Some CG titles explicitly include 'Step Therapy' in the title (e.g., Rituximab Agents for Oncologic Indications Step Therapy), indicating sequencing rules exist in the referenced guideline.

Titles including 'Step Therapy' indicate sequencing in that CG

References to 'Step Therapy' appear as part of certain CG titles in the index, signaling that those specific guideline documents contain step therapy sequencing; the index itself does not provide the sequencing details.

• When a CG title includes 'Step Therapy', follow that guideline's documented step failures and required trials for authorization.

No step therapy rules present in this fragment

This extract does not include step therapy rules or sequencing information; providers must review each referenced clinical guideline to determine whether step therapy applies.

• The index lists many drug names and CG references but does not specify required prior agents, durations, or failure criteria.

Step therapy — none specified in index

The index provides no explicit step therapy requirements; absence of sequencing in the extract means providers should consult the full CG documents for any step therapy policies.

No step therapy details available

No step therapy operational details (such as required trials, durations, or failure criteria) are present in these chunks; the index only identifies which guidelines to consult.

Contact member ID back‑of‑card phone to confirm precertification

For information about precertification requirements or to confirm whether precertification is required for a specific member, providers should call the phone number on the back of the member's ID card; the provider will also be notified upon requesting precertification if it is required.

• If the account has not purchased the Pre‑Payment Review Program, precertification is not required and clinical review will not be performed.

No documentation requirements in index — consult individual CGs

This index portion does not contain documentation or submission requirements; it primarily lists CG numbers, guideline titles, and occasional implementation dates — providers must refer to individual CGs for documentation needed for authorization.

Provider will be notified upon requesting precertification

When a provider requests precertification, the plan will notify whether precertification is required for the member; contact information is available on the member ID card.

• Notification upon request is the mechanism for confirming whether a purchased program requires precertification for that member.

No submission or documentation instructions in this extract

This fragment does not include documentation or submission instructions (forms, supporting clinical data, or billing codes); providers should obtain those requirements from the individual CG or the precertification contact.

Do not require PA for biomarker testing in stage 3–4 cancer; confirmation allowed

Confirmation of advanced or metastatic stage 3 or 4 cancer is permitted for post‑service review of biomarker testing, but effective July 1, 2022, prior authorization will no longer be required for biomarker testing for members with advanced or metastatic stage 3 or 4 cancer; post‑service medical necessity review for those members is not permitted except to confirm stage.

• This change is effective July 1, 2022, per California SB 535 compliance noted in the guideline.

Missing precertification may lead to administrative denial when program purchased

If precertification is required and not obtained for a member covered under a purchased Pre‑Payment Review Program, lack of required precertification may trigger administrative denial or notification; conversely, if the program has not been purchased by the account, precertification is not required and clinical review will not be performed.

• Providers will be notified upon requesting precertification whether precertification is required for the member.

No explicit denial triggers in index — consult CGs

This fragment is an index of CG numbers and titles and does not state explicit denial triggers; providers must refer to each clinical guideline for specific authorization triggers and denial criteria.

Precertification not required if program not purchased by account

If the account has not purchased the Pre‑Payment Review Program (for example, a prior authorization program), precertification is not required and clinical review will not be performed; providers will be notified when requesting precertification if the program applies to the member.

Infusion center — see CG‑MED‑83 Site of Care

Site‑of‑care policies are referenced for specialty pharmaceuticals (see CG‑MED‑83 Site of Care: Specialty Pharmaceuticals); providers should consult that guideline for site‑of‑care rules applicable to infusion centers.

Hospital outpatient — Carelon surgical site‑of‑care review applies for select accounts

Carelon Surgical Procedures — Site‑of‑Care Review and related surgical procedure resources apply for select accounts; providers should reference the Carelon surgical site‑of‑care guideline and surgical procedure checklist when site‑of‑care review is required for hospital outpatient settings.