MedicaidOctober 29, 2024
Clinical Criteria updates
Effective January 30, 2025
Summary:
On August 16, 2024, 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. For 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 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.
- 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 |
January 30, 2025 | *CC-0266 | Rytelo (imetelstat) | New |
January 30, 2025 | CC-0156 | Reblozyl (luspatercept) | Revised
|
January 30, 2025 | CC-0244 | Columvi (glofitamab-gxbm) | Revised |
January 30, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised |
January 30, 2025 | CC-0104 | Levoleucovorin Agents | Revised |
January 30, 2025 | CC-0182 | Iron Agents | Revised |
January 30, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
January 30, 2025 | CC-0247 | Beyfortus (nirsevimab) | Revised |
January 30, 2025 | *CC-0007 | Synagis (palivizumab) | Revised |
January 30, 2025 | *CC-0082 | Onpattro (patisiran) | Revised |
January 30, 2025 | *CC-0217 | Amvuttra (vulrisiran) | Revised |
January 30, 2025 | *CC-0084 | Tegsedi (inotersen) | Revised |
January 30, 2025 | *CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
January 30, 2025 | CC-0209 | Leqvio (inclisiran) | Revised |
January 30, 2025 | *CC-0193 | Evkeeza (evinacumab) | Revised |
January 30, 2025 | *CC-0027 | Denosumab | Revised |
January 30, 2025 | CC-0019 | Zoledronic Acid | Revised |
January 30, 2025 | CC-0208 | Adbry (tralokinumab) | Revised |
January 30, 2025 | *CC-0029 | Dupixent (dupilumab) | Revised |
January 30, 2025 | *CC-0246 | Rystiggo (rozanolixizumab-noli) | Revised |
January 30, 2025 | *CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised |
January 30, 2025 | *CC-0028 | Benlysta (belimumab) | Revised |
January 30, 2025 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
January 30, 2025 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
January 30, 2025 | CC-0121 | Gazyva (obinutuzumab) | Revised |
January 30, 2025 | CC-0242 | Epkinly (epcoritamab-bysp) | Revised |
January 30, 2025 | CC-0130 | Imfinzi (durvalumab) | Revised |
January 30, 2025 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
January 30, 2025 | CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
January 30, 2025 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
January 30, 2025 | CC-0071 | Entyvio (vedolizumab) | Revised |
January 30, 2025 | *CC-0048 | Spinraza (nusinersen) | Revised |
January 30, 2025 | *CC-0003 | Immunoglobulins | Revised |
January 30, 2025 | *CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | 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-070777-24-CPN70546
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Visit https://providernews.anthem.com/california/articles/clinical-criteria-updates-22701
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