MedicaidApril 24, 2024
Clinical Criteria updates — November 2023
Summary
On February 24, 2023, and November 17, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. 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 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 providers in 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.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised |
July 25, 2024 | *CC-0252 | Adzynma (ADAMTS13, recombinant-krhn) | New |
July 25, 2024 | *CC-0253 | Aphexda (motixafortide) | New |
July 25, 2024 | *CC-0254 | Zilbysq (zilucoplan) | New |
July 25, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
July 25, 2024 | CC-0223 | Imjudo (tremelimumab-actl) | Revised |
July 25, 2024 | *CC-0059 | Selected Injectable NK-1 Antiemetic Agents | Revised |
July 25, 2024 | CC-0074 | Akynzeo (fosnetupitant and palonosetron) for injection | Revised |
July 25, 2024 | *CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
July 25, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
July 25, 2024 | CC-0150 | Kymriah (tisagenlecleucel) | Revised |
July 25, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
July 25, 2024 | CC-0133 | Aliqopa (copanlisib) | Revised |
July 25, 2024 | CC-0205 | Fyarro (sirolimus albumin bound) | Revised |
July 25, 2024 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
July 25, 2024 | *CC-0226 | Elahere (mirvetuximab) | Revised |
July 25, 2024 | CC-0125 | Opdivo (nivolumab) | Revised |
July 25, 2024 | CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | Revised |
July 25, 2024 | *CC-0009 | Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis | Revised |
July 25, 2024 | *CC-0014 | Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis |
Revised |
July 25, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
July 25, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
July 25, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
July 25, 2024 | *CC-0032 | Botulinum Toxin | Revised |
July 25, 2024 | *CC-0068 | Growth Hormone | Revised |
July 25, 2024 | *CC-0173 | Enspryng (satralizumab-mwge) | Revised |
July 25, 2024 | *CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
July 25, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
July 25, 2024 | *CC-0041 | Complement Inhibitors | Revised |
July 25, 2024 | *CC-0071 | Entyvio (vedolizumab) | Revised |
July 25, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
July 25, 2024 | *CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
July 25, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
July 25, 2024 | *CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
July 25, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
July 25, 2024 | *CC-0063 | Ustekinumab Agents | Revised |
July 25, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
July 25, 2024 | CC-0003 | Immunoglobulins | Revised |
July 25, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
July 25, 2024 | CC-0247 | Beyfortus (nirsevimab) | Revised |
July 25, 2024 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
July 25, 2024 | CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
July 25, 2024 | CC-0209 | Leqvio (inclisiran) | Revised |
July 25, 2024 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
CABC-CD-050611-24-CPN49889
PUBLICATIONS: May 2024 Provider Newsletter
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