Medicare AdvantageApril 1, 2021
Clinical Criteria updates notification November 2020
On June 18, 2020, August 21, 2020, and November 20, 2020, the Pharmacy and Therapeutics (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. If you have questions or would like 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 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 policy. This does not apply to pharmacy services.
Effective date |
Document number |
Clinical Criteria title |
New or revised |
March 26, 2021 |
ING-CC-0183* |
Sogroya (somapacitan-beco) |
New |
March 26, 2021 |
ING-CC-0148* |
Agents for Hemophilia B |
Revised |
March 26, 2021 |
ING-CC-0149* |
Select Clotting Agents for Bleeding Disorders |
Revised |
March 26, 2021 |
ING-CC-0065 |
Agents for Hemophilia A and von Willebrand Disease |
Revised |
March 26, 2021 |
ING-CC-0125 |
Opdivo (nivolumab) |
Revised |
March 26, 2021 |
ING-CC-0119 |
Yervoy (ipilimumab) |
Revised |
March 26, 2021 |
ING-CC-0121* |
Gazyva (obinutuzumab) |
Revised |
March 26, 2021 |
ING-CC-0048 * |
Spinraza (nusinersen) |
Revised |
March 26, 2021 |
ING-CC-0002* |
Colony Stimulating Factor Agents |
Revised |
March 26, 2021 |
ING-CC-0034* |
Hereditary Angioedema Agents |
Revised |
March 26, 2021 |
ING-CC-0041* |
Complement Inhibitors |
Revised |
March 26, 2021 |
ING-CC-0071* |
Entyvio (vedolizumab) |
Revised |
March 26, 2021 |
ING-CC-0064* |
Interleukin-1 Inhibitors |
Revised |
March 26, 2021 |
ING-CC-0042* |
Monoclonal Antibodies to Interleukin-17 |
Revised |
March 26, 2021 |
ING-CC-0066* |
Monoclonal Antibodies to Interleukin-6 |
Revised |
March 26, 2021 |
ING-CC-0050* |
Monoclonal Antibodies to Interleukin-23 |
Revised |
March 26, 2021 |
ING-CC-0078* |
Orencia (abatacept) |
Revised |
March 26, 2021 |
ING-CC-0063* |
Stelara (ustekinumab) |
Revised |
March 26, 2021 |
ING-CC-0062* |
Tumor Necrosis Factor Antagonists |
Revised |
March 26, 2021 |
ING-CC-0003* |
Immunoglobulins |
Revised |
March 26, 2021 |
ING-CC-0039* |
GamaSTAN [immune globulin (human)] |
Revised |
March 26, 2021 |
ING-CC-0053 |
Injectable Hydroxyprogesterone for Prevention of Preterm Birth |
Revised |
March 26, 2021 |
ING-CC-0073* |
Alpha-1 Proteinase Inhibitor Therapy |
Revised |
March 26, 2021 |
ING-CC-0075 |
Rituximab Agents for Non-Oncologic Indications |
Revised |
March 26, 2021 |
ING-CC-0072 |
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists |
Revised |
March 26, 2021 |
ING-CC-0027* |
Denosumab Agents |
Revised |
March 26, 2021 |
ING-CC-0019* |
Zoledronic Acid Agents (Reclast, Zometa) |
Revised |
March 26, 2021 |
ING-CC-0011* |
Ocrevus (ocrelizumab) |
Revised |
March 26, 2021 |
*ING-CC-0174* |
Kesimpta (ofatumumab) |
Revised |
517460MUPNMUB
PUBLICATIONS: April 2021 Anthem Blue Cross Provider News - California
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