Policy UpdatesMedicaidNovember 6, 2024

Clinical Criteria updates

Effective February 9, 2025

Summary: On May 17, 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 providers in your practice and office staff.

Please note:

  • The Clinical Criteria listed below apply 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 have 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

February 9, 2025

*CC-0262

Tevimbra (tislelizumab-jsgr)

New

February 9, 2025

*CC-0162

Tepezza (teprotumumab-trbw)

Revised

February 9, 2025

*CC-0111

Nplate (romiplostim)

Revised

February 9, 2025

CC-0165

Trodelvy (sacituzumab govitecan)

Revised

February 9, 2025

*CC-0002

Colony Stimulating Factor Agents

Revised

February 9, 2025

CC-0128

Tecentriq (atezolizumab)

Revised

February 9, 2025

*CC-0098

Doxorubicin Liposome (Doxil, Lipodox)

Revised

February 9, 2025

*CC-0101

Torisel (temsirolimus)

Revised

February 9, 2025

*CC-0107

Bevacizumab for Non-Ophthalmologic Indications

Revised

February 9, 2025

CC-0143

Polivy (polatuzumab vedotin-piiq)

Revised

February 9, 2025

*CC-0092

Adcetris (brentuximab vedotin)

Revised

February 9, 2025

CC-0106

Erbitux (cetuximab)

Revised

February 9, 2025

*CC-0105

Vectibix (panitumumab)

Revised

February 9, 2025

CC-0145

Libtayo (cemiplimab-rwlc)

Revised

February 9, 2025

CC-0160

Vyepti (eptinezumab)

Revised

February 9, 2025

CC-0102

GNRH Analogs for Oncologic Indications

Revised

February 9, 2025

CC-0201

Rybrevant (amivantamab-ymjw)

Revised

February 9, 2025

*CC-0124

Keytruda (pembrolizumab)

Revised

February 9, 2025

CC-0041

Complement C5 Inhibitors

Revised

February 9, 2025

CC-0199

Empaveli (pegcetacoplan)

Revised

February 9, 2025

*CC-0130

Imfinzi (durvalumab)

Revised

February 9, 2025

CC-0240

Zynyz (retifanlimab-dlwr)

Revised

February 9, 2025

CC-0123

Cyramza (ramucirumab)

Revised

February 9, 2025

CC-0187

Breyanzi (lisocabtagene maraleucel)

Revised

February 9, 2025

CC-0158

Enhertu (fam-trastuzumab deruxtecan-nxki)

Revised

February 9, 2025

CC-0226

Elahere (mirvetuximab)

Revised

February 9, 2025

CC-0043

Monoclonal Antibodies to Interleukin-5

Revised

February 9, 2025

*CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

February 9, 2025

CC-0221

Spevigo (spesolimab-sbzo)

Revised

February 9, 2025

CC-0071

Entyvio (vedolizumab)

Revised

February 9, 2025

*CC-0063

Ustekinumab 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-063651-24-CPN63281