On March 25, 2021, and April 8, 2021, 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.

 

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

September 3, 2021

ING-CC-0195*

Abecma (idecabtagene vicleucel)

New

September 3, 2021

ING-CC-0191*

Pepaxto (melphalan flufenamide; melflufen)

New

September 3, 2021

ING-CC-0192*

Cosela (trilaciclib)

New

September 3, 2021

ING-CC-0193*

Evkeeza (evinacumab)

New

September 3, 2021

ING-CC-0125

Opdivo (nivolumab)

Revised

September 3, 2021

ING-CC-0064

Interleukin-1 Inhibitors

Revised

September 3, 2021

ING-CC-0159*

Scenesse (afamelanotide)

Revised

September 3, 2021

ING-CC-0151

Yescarta (axicabtagene ciloleucel)

Revised

September 3, 2021

ING-CC-0145*

Libtayo (cemiplimab-rwlc)

Revised

September 3, 2021

ING-CC-0130*

Imfinzi (durvalumab)

Revised

September 3, 2021

ING-CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

September 3, 2021

ING-CC-0075*

Rituximab Agents for Non-Oncologic Indications

Revised

 

ACA-NU-0358-21



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