On June 18, 2020, August 21, 2020, and November 20, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. If you have questions or would like 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
  • Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

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 policy. This does not apply to pharmacy services.

 

Effective date

Document number

Clinical Criteria title

New or revised

March 26, 2021

ING-CC-0183*

Sogroya (somapacitan-beco)

New

March 26, 2021

ING-CC-0148*

Agents for Hemophilia B

Revised

March 26, 2021

ING-CC-0149*

Select Clotting Agents for Bleeding Disorders

Revised

March 26, 2021

ING-CC-0065

Agents for Hemophilia A and von Willebrand Disease

Revised

March 26, 2021

ING-CC-0125

Opdivo (nivolumab)

Revised

March 26, 2021

ING-CC-0119

Yervoy (ipilimumab)

Revised

March 26, 2021

ING-CC-0121*

Gazyva (obinutuzumab)

Revised

March 26, 2021

ING-CC-0048 *

Spinraza (nusinersen)

Revised

March 26, 2021

ING-CC-0002*

Colony Stimulating Factor Agents

Revised

March 26, 2021

ING-CC-0034*

Hereditary Angioedema Agents

Revised

March 26, 2021

ING-CC-0041*

Complement Inhibitors

Revised

March 26, 2021

ING-CC-0071*

Entyvio (vedolizumab)

Revised

March 26, 2021

ING-CC-0064*

Interleukin-1 Inhibitors

Revised

March 26, 2021

ING-CC-0042*

Monoclonal Antibodies to Interleukin-17

Revised

March 26, 2021

ING-CC-0066*

Monoclonal Antibodies to Interleukin-6

Revised

March 26, 2021

ING-CC-0050*

Monoclonal Antibodies to Interleukin-23

Revised

March 26, 2021

ING-CC-0078*

Orencia (abatacept)

Revised

March 26, 2021

ING-CC-0063*

Stelara (ustekinumab)

Revised

March 26, 2021

ING-CC-0062*

Tumor Necrosis Factor Antagonists

Revised

March 26, 2021

ING-CC-0003*

Immunoglobulins

Revised

March 26, 2021

ING-CC-0039*

GamaSTAN [immune globulin (human)]

Revised

March 26, 2021

ING-CC-0053

Injectable Hydroxyprogesterone for Prevention of Preterm Birth

Revised

March 26, 2021

ING-CC-0073*

Alpha-1 Proteinase Inhibitor Therapy

Revised

March 26, 2021

ING-CC-0075

Rituximab Agents for Non-Oncologic Indications

Revised

March 26, 2021

ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Revised

March 26, 2021

ING-CC-0027*

Denosumab Agents

Revised

March 26, 2021

ING-CC-0019*

Zoledronic Acid Agents (Reclast, Zometa)

Revised

March 26, 2021

ING-CC-0011*

Ocrevus (ocrelizumab)

Revised

March 26, 2021

*ING-CC-0174*

Kesimpta (ofatumumab)

Revised

 

517460MUPNMUB



Featured In:
April 2021 Anthem Blue Cross Provider News - California