State & FederalMedicare AdvantageMarch 1, 2019

Clinical criteria updates for specialty pharmacy

The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

Clinical criteria effective date

Clinical criteria number

Clinical criteria

Clinical criteria (new/revised)

May 1, 2019

ING-CC-0001

Erythropoiesis Stimulating Agents

Revised

May 1, 2019

ING-CC-0004

H.P. Acthar Gel®

(repository corticotropin injection)

Revised

May 1, 2019

ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Revised




75743MUPENMUB 01/24/2019