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

 

518315MUPENMUB

 

 

 



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