MedicaidFebruary 26, 2025
Clinical Criteria updates
Effective May 28, 2025
Summary: The Pharmacy and Therapeutics (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
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 plan. 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 |
May 28, 2025 | CC-0272 | Aucatzyl (obecabtagene autoleucel) | New |
May 28, 2025 | CC-0273 | Vyloy (zolbetuximab-clzb) | New |
May 28, 2025 | CC-0223 | Imjudo (tremelimumab-actl) | Revised |
May 28, 2025 | CC-0056 | Selected Injectable 5HT3 Antiemetic Agents | Revised |
May 28, 2025 | CC-0148 | Agents for Hemophilia B | Revised |
May 28, 2025 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised |
May 28, 2025 | CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
May 28, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised |
May 28, 2025 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised |
May 28, 2025 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
May 28, 2025 | CC-0204 | Tivdak (tisotumab vedotin-tftv) | Revised |
May 28, 2025 | CC-0226 | Elahere (mirvetuximab) | Revised |
May 28, 2025 | CC-0125 | Opdivo (nivolumab) | Revised |
May 28, 2025 | CC-0128 | Tecentriq (atezolizumab) | Revised |
May 28, 2025 | CC-0011 | Ocrevus (ocrelizumab)/Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) | Revised |
May 28, 2025 | CC-0173 | Enspryng (satralizumab-mwge) | Revised |
May 28, 2025 | CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
May 28, 2025 | CC-0199 | Empaveli (pegcetacoplan) | Revised |
May 28, 2025 | CC-0041 | Complement Inhibitors | Revised |
May 28, 2025 | CC-0071 | Entyvio (vedolizumab) | Revised |
May 28, 2025 | CC-0064 | Interleukin-1 Inhibitors | Revised |
May 28, 2025 | CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
May 28, 2025 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
May 28, 2025 | CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
May 28, 2025 | CC-0078 | Orencia (abatacept) | Revised |
May 28, 2025 | CC-0063 | Ustekinumab Agents | Revised |
May 28, 2025 | CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
May 28, 2025 | CC-0003 | Immunoglobulins | Revised |
May 28, 2025 | CC-0073 | Alpha-1 Proteinase Inhibitor Therapy | Revised |
May 28, 2025 | CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
May 28, 2025 | CC-0029 | Dupixent (dupilumab) | Revised |
May 28, 2025 | CC-0105 | Vectibix (panitumumab) | Revised |
May 28, 2025 | CC-0095 | Bortezomib (Boruzu, Velcade) | Revised |
May 28, 2025 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
May 28, 2025 | CC-0201 | Rybrevant (amivantamab-vmjw) | Revised |
May 28, 2025 | CC-0120 | Kyprolis (carfilzomib) | Revised |
May 28, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
May 28, 2025 | CC-0255 | Loqtorzi (toripalimab-tpzi) | Revised |
May 28, 2025 | CC-0001 | Erythropoiesis Stimulating Agents | Revised |
May 28, 2025 | CC-0002 | Colony Stimulating Factor 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-076580-25-CPN76226
PUBLICATIONS: April 2025 Provider Newsletter
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Visit https://providernews.anthem.com/california/articles/clinical-criteria-updates-24305
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