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Anthem provides clarification on scope of CVS specialty medication policy

November 19, 2020
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement 


In September 2020, Anthem Blue Cross sent notices to affected physicians and hospitals advising that it would begin requiring them to obtain certain specialty medications administered in the office or outpatient hospital setting for commercial PPO and EPO patients through CVS Specialty pharmacy. The notice indicated the policy will be effective for dates of service on or after December 1, 2020.

The California Medical Association (CMA) recently met with Anthem representatives to seek clarification on this policy, as the scope of affected physicians was unclear.

Anthem has clarified that while the new EPO and PPO policy will mirror what was previously implemented in July 2020 for Anthem commercial HMO and Medi-Cal managed care plans, this recent notification will only apply to a small subset of hospitals and providers within its network. Providers who did not receive the notification directly from Anthem can continue to administer and bill for these specialty medications per their standard processes.

If your practice received a letter indicating you must acquire specialty drugs through CVS Specialty and you would like to discuss options, confirm whether your practice is included in the CVS Specialty requirement, or ask further questions or express concerns, please contact Anthem Network Relations at CAcontractsupport@Anthem.com

For additional assistance, please contact Mark Lane in CMA’s Center for Economic Services at (888) 401-5911 or mlane@cmadocs.org.

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