MedicaidDecember 4, 2023
Clinical Criteria updates — August 2023
Summary: On May 19, 2023, August 18, 2023, and August 30, 2023, the Pharmacy and Therapeutic (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. 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 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 |
March 11, 2024 | *CC-0244 | Columvi (glofitamab-gxbm) | New |
March 11, 2024 | *CC-0245 | Izervay (avacincaptad pegol) | New |
March 11, 2024 | *CC-0246 | Rystiggo (rozanolixizumab-noli) | New |
March 11, 2024 | *CC-0247 | Beyfortus (nirsevimab) | New |
March 11, 2024 | CC-0001 | Erythropoiesis Stimulating Agents | Revised |
March 11, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
March 11, 2024 | CC-0104 | Levoleucovorin Agents | Revised |
March 11, 2024 | CC-0100 | Romidepsin | Revised |
March 11, 2024 | *CC-0182 | Iron Agents | Revised |
March 11, 2024 | CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised |
March 11, 2024 | CC-0176 | Beleodaq (belinostat) | Revised |
March 11, 2024 | CC-0180 | Monjuvi (tafasitamab-cxix) | Revised |
March 11, 2024 | CC-0107 | Bevacizumab for non-ophthalmologic indications | Revised |
March 11, 2024 | CC-0216 | Opdualag (nivolumab and relatlimab-rmbw) | Revised |
March 11, 2024 | CC-0196 | Zynlonta (loncastuximab tesirine-lpyl) | Revised |
March 11, 2024 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
March 11, 2024 | CC-0203 | Ryplazim (plasminogen, human-tvmh) | Revised |
March 11, 2024 | CC-0193 | Evkeeza (evinacumab) | Revised |
March 11, 2024 | *CC-0034 | Hereditary Angioedema Agents | Revised |
March 11, 2024 | *CC-0041 | Complement Inhibitors | Revised |
March 11, 2024 | *CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised |
March 11, 2024 | CC-0028 | Benlysta (belimumab) | Revised |
March 11, 2024 | *CC-0243 | Vyjuvek (beremagene geperpavec) | Revised |
March 11, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
March 11, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised |
March 11, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised |
March 11, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
March 11, 2024 | *CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
March 11, 2024 | *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-044608-23-CPN44139
PUBLICATIONS: January 2024 Provider Newsletter
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