MedicaidJune 12, 2023
Clinical Criteria Updates for February 2023
Summary: On May 20, 2022, August 19, 2022, September 12, 2022, September 15, 2022, November 18, 2022, December 12, 2022, and February 24, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (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 | Document number | Clinical Criteria title | New or revised |
September 12, 2023 | *CC-0232 | Lunsumio (mosunetuzumab-axgb) | New |
September 12, 2023 | *CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | New |
September 12, 2023 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | New |
September 12, 2023 | *CC-0234 | Syfovre (pegcetacoplan) | New |
September 12, 2023 | *CC-0231 | Lamzede (velmanase alfa-tycv) | New |
September 12, 2023 | CC-0007 | Synagis (palivizumab) | Revised |
September 12, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
September 12, 2023 | CC-0210 | Enjaymo (sutimlimab-jome) | Revised |
September 12, 2023 | *CC-0128 | Tecentriq (atezolizumab) | Revised |
September 12, 2023 | *CC-0116 | Bendamustine agents | Revised |
September 12, 2023 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
September 12, 2023 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
September 12, 2023 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
September 12, 2023 | *CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
September 12, 2023 | CC-0125 | Opdivo (nivolumab) | Revised |
September 12, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised |
September 12, 2023 | CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
September 12, 2023 | *CC-0093 | Docetaxel (Taxotere) | Revised |
September 12, 2023 | CC-0094 | Pemetrexed Agents (Alimta, Pemfexy) | Revised |
September 12, 2023 | CC-0130 | Imfinzi (durvalumab) | Revised |
September 12, 2023 | CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
September 12, 2023 | CC-0123 | Cyramza (ramucirumab) | Revised |
September 12, 2023 | CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
September 12, 2023 | CC-0121 | Gazyva (obinutuzumab) | Revised |
September 12, 2023 | *CC-0096 | Asparagine Specific Enzymes | Revised |
September 12, 2023 | *CC-0120 | Kyprolis (carfilzomib) | Revised |
September 12, 2023 | CC-0117 | Empliciti (elotuzumab) | Revised |
September 12, 2023 | CC-0126 | Blincyto (blinatumomab) | Revised |
September 12, 2023 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
September 12, 2023 | CC-0097 | Vidaza (azacitidine) | Revised |
September 12, 2023 | CC-0129 | Bavencio (avelumab) | Revised |
September 12, 2023 | CC-0090 | Ixempra (ixabepilone) | Revised |
September 12, 2023 | *CC-0110 | Perjeta (pertuzumab) | Revised |
September 12, 2023 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
September 12, 2023 | CC-0124 | Keytruda (pembrolizumab) | Revised |
September 12, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
September 12, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
September 12, 2023 | *CC-0160 | Vyepti (eptinezumab) | Revised |
September 12, 2023 | *CC-0034 | Hereditary Angioedema Agents | Revised |
September 12, 2023 | *CC-0020 | Tysabri (natalizumab) | Revised |
September 12, 2023 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
September 12, 2023 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
September 12, 2023 | *CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
September 12, 2023 | *CC-0001 | Erythropoiesis Stimulating Agents | Revised |
September 12, 2023 | *CC-0166 | Trastuzumab Agents | Revised |
September 12, 2023 | *CC-0075 | Rituximab agents for Non-Oncologic Indications | Revised |
September 12, 2023 | *CC-0167 | Rituximab Agents for Oncologic Indications | Revised |
September 12, 2023 | *CC-0209 | Leqvio (inclisiran) | Revised |
September 12, 2023 | *CC-0182 | Iron Agents | Revised |
September 12, 2023 | *CC-0107 | Bevacizumab for Non-ophthalmologic Indications | Revised |
September 12, 2023 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
CABC-CD-024307-23-CPN24009
PUBLICATIONS: July 2023 Provider Newsletter
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