June 1, 2021
Medical drug benefit clinical criteria updates
On February 19, 2021, and March 4, 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 |
|
May 30, 2021 |
ING-CC-0186* |
Margenza (margetuximab-cmkb) |
New |
|
May 30, 2021 |
ING-CC-0187* |
Breyanzi (lisocabtagene maraleucel) |
New |
|
May 30, 2021 |
ING-CC-0189* |
Amondys 45 (casimersen) |
New |
|
May 30, 2021 |
ING-CC-0190* |
Nulibry (fosdenopterin) |
New |
|
May 30, 2021 |
ING-CC-0086* |
Spravato (esketamine) Nasal Spray |
Revised |
|
May 30, 2021 |
ING-CC-0158 |
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Revised |
|
May 30, 2021 |
ING-CC-0167 |
Rituximab Agents for Oncologic Indications Step Therapy |
Revised |
|
May 30, 2021 |
ING-CC-0157* |
Padcev (enfortumab vedotin) |
Revised |
|
May 30, 2021 |
ING-CC-0125* |
Opdivo (nivolumab) |
Revised |
|
May 30, 2021 |
ING-CC-0119* |
Yervoy (ipilimumab) |
Revised |
|
May 30, 2021 |
ING-CC-0099 |
Abraxane (paclitaxel, protein bound) |
Revised |
|
May 30, 2021 |
ING-CC-0094* |
Pemetrexed Agents (Alimta, Pemfexy) |
Revised |
|
May 30, 2021 |
ING-CC-0123* |
Cyramza (ramucirumab) |
Revised |
|
May 30, 2021 |
ING-CC-0115* |
Kadcyla (ado-trastuzumab) |
Revised |
|
May 30, 2021 |
ING-CC-0033* |
Xolair (omalizumab) |
Revised |
|
May 30, 2021 |
ING-CC-0043 |
Monoclonal Antibodies to Interleukin-5 |
Revised |
|
May 30, 2021 |
ING-CC-0067* |
Prostacyclin Infusion and Inhalation Therapy |
Revised |
|
May 30, 2021 |
ING-CC-0075* |
Rituximab Agents for Non-Oncologic Indications |
Revised |
|
May 30, 2021 |
ING-CC-0034* |
Hereditary Angioedema Agents |
Revised |
|
May 30, 2021 |
ING-CC-0028* |
Benlysta (belimumab) |
Revised |
PUBLICATIONS: June 2021 Anthem Blue Cross Provider News - California
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