MedicaidMay 29, 2024
Clinical Criteria updates
Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 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. If you have questions or need 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 |
August 27, 2024 | *CC-0258 | iDoseTR (travoprost Implant) | New |
August 27, 2024 | *CC-0259 | Amtagvi (lifleucel) | New |
August 27, 2024 | *CC-0260 | Nexobrid (anacaulase-bcdb) | New |
August 27, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
August 27, 2024 | *CC-0041 | Complement Inhibitors | Revised |
August 27, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
August 27, 2024 | CC-0116 | Bendamustine agents | Revised |
August 27, 2024 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
August 27, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
August 27, 2024 | CC-0157 | Padcev (enfortumab vedotin) | Revised |
August 27, 2024 | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | Revised |
August 27, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised |
August 27, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised |
August 27, 2024 | *CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
August 27, 2024 | *CC-0093 | Docetaxel (Taxotere) | Revised |
August 27, 2024 | *CC-0094 | Pemetrexed (Alimta, Pemfexy, Pemrydi) | Revised |
August 27, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
August 27, 2024 | *CC-0088 | Elzonris (tagraxofusp-erzs) | Revised |
August 27, 2024 | *CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
August 27, 2024 | *CC-0112 | Xofigo (Radium Ra 223 Dichloride) | Revised |
August 27, 2024 | *CC-0123 | Cyramza (ramucirumab) | Revised |
August 27, 2024 | *CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
August 27, 2024 | CC-0121 | Gazyva (obinutuzumab) | Revised |
August 27, 2024 | CC-0122 | Arzerra (ofatumumab) | Revised |
August 27, 2024 | CC-0232 | Lunsumio (mosunetuzumab-axgb) | Revised |
August 27, 2024 | CC-0109 | Zaltrap (ziv-aflibercept) | Revised |
August 27, 2024 | CC-0135 | Melanoma Vaccines | Revised |
August 27, 2024 | *CC-0096 | Asparagine Specific Enzymes | Revised |
August 27, 2024 | CC-0120 | Kyprolis (carfilzomib) | Revised |
August 27, 2024 | *CC-0117 | Empliciti (elotuzumab) | Revised |
August 27, 2024 | *CC-0126 | Blincyto (blinatumomab) | Revised |
August 27, 2024 | CC-0113 | Sylvant (siltuximab) | Revised |
August 27, 2024 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
August 27, 2024 | CC-0097 | Vidaza (azacitidine) | Revised |
August 27, 2024 | CC-0129 | Bavencio (avelumab) | Revised |
August 27, 2024 | *CC-0090 | Ixempra (ixabepilone) | Revised |
August 27, 2024 | CC-0110 | Perjeta (pertuzumab) | Revised |
August 27, 2024 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
August 27, 2024 | *CC-0108 | Halaven (eribulin) | Revised |
August 27, 2024 | CC-0089 | Mozobil (plerixafor) | Revised |
August 27, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
August 27, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
August 27, 2024 | *CC-0212 | Tezspire (tezepelumab-ekko) | Revised |
August 27, 2024 | *CC-0033 | Xolair (omalizumab) | Revised |
August 27, 2024 | *CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
August 27, 2024 | *CC-0029 | Dupixent (dupilumab) | Revised |
August 27, 2024 | *CC-0208 | Adbry (tralokinumab) | Revised |
August 27, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
August 27, 2024 | *CC-0067 | Prostacyclin Infusion and Inhalation Therapy | Revised |
August 27, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
August 27, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
August 27, 2024 | *CC-0057 | Krystexxa (pegloticase) | Revised |
August 27, 2024 | *CC-0068 | Growth Hormones | Revised |
August 27, 2024 | *CC-0047 | Trogarzo | Revised |
August 27, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
August 27, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
August 27, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
August 27, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | 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-058997-24-CPN57972
PUBLICATIONS: July 2024 Provider Newsletter
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Visit https://providernews.anthem.com/california/articles/clinical-criteria-updates-effective-19876
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