April 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 (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 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 |
April 5, 2021 |
ING-CC-0183* |
Sogroya (somapacitan-beco) |
New |
April 5, 2021 |
ING-CC-0148* |
Agents for Hemophilia B |
Revised |
April 5, 2021 |
ING-CC-0149* |
Select Clotting Agents for Bleeding Disorders |
Revised |
April 5, 2021 |
ING-CC-0065 |
Agents for Hemophilia A and von Willebrand Disease |
Revised |
April 5, 2021 |
ING-CC-0125 |
Opdivo (nivolumab) |
Revised |
April 5, 2021 |
ING-CC-0119 |
Yervoy (ipilimumab) |
Revised |
April 5, 2021 |
ING-CC-0121* |
Gazyva (obinutuzumab) |
Revised |
April 5, 2021 |
ING-CC-0048 * |
Spinraza (nusinersen) |
Revised |
April 5, 2021 |
ING-CC-0002* |
Colony Stimulating Factor Agents |
Revised |
April 5, 2021 |
ING-CC-0034* |
Hereditary Angioedema Agents |
Revised |
April 5, 2021 |
ING-CC-0041* |
Complement Inhibitors |
Revised |
April 5, 2021 |
ING-CC-0071* |
Entyvio (vedolizumab) |
Revised |
April 5, 2021 |
ING-CC-0064* |
Interleukin-1 Inhibitors |
Revised |
April 5, 2021 |
ING-CC-0042* |
Monoclonal Antibodies to Interleukin-17 |
Revised |
April 5, 2021 |
ING-CC-0066* |
Monoclonal Antibodies to Interleukin-6 |
Revised |
April 5, 2021 |
ING-CC-0050* |
Monoclonal Antibodies to Interleukin-23 |
Revised |
April 5, 2021 |
ING-CC-0078* |
Orencia (abatacept) |
Revised |
April 5, 2021 |
ING-CC-0063* |
Stelara (ustekinumab) |
Revised |
April 5, 2021 |
ING-CC-0062* |
Tumor Necrosis Factor Antagonists |
Revised |
April 5, 2021 |
ING-CC-0003* |
Immunoglobulins |
Revised |
April 5, 2021 |
ING-CC-0039* |
GamaSTAN [immune globulin (human)] |
Revised |
April 5, 2021 |
ING-CC-0053 |
Injectable Hydroxyprogesterone for Prevention of Preterm Birth |
Revised |
April 5, 2021 |
ING-CC-0073* |
Alpha-1 Proteinase Inhibitor Therapy |
Revised |
April 5, 2021 |
ING-CC-0075 |
Rituximab Agents for Non-Oncologic Indications |
Revised |
April 5, 2021 |
ING-CC-0072 |
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists |
Revised |
April 5, 2021 |
ING-CC-0027* |
Denosumab Agents |
Revised |
April 5, 2021 |
ING-CC-0019* |
Zoledronic Acid Agents (Reclast, Zometa) |
Revised |
April 5, 2021 |
ING-CC-0011* |
Ocrevus (ocrelizumab) |
Revised |
April 5, 2021 |
*ING-CC-0174* |
Kesimpta (ofatumumab) |
Revised |
517460MUPENMUB
PUBLICATIONS: April 2021 Anthem Blue Cross Provider News - California
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