MedicaidJune 1, 2022
Medical drug benefit Clinical Criteria updates
On November 19, 2021, January 4, 2022, and February 25, 2022, 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.
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 |
|
August 8, 2022 |
*ING-CC-0211 |
Kimmtrak (tebentafusp-tebn) |
New |
|
August 8, 2022 |
*ING-CC-0210 |
Enjaymo (sutimlimab-jome) |
New |
|
August 8, 2022 |
*ING-CC-0213 |
Voxzogo (vosoritide) |
New |
|
August 8, 2022 |
*ING-CC-0212 |
Tezspire (tezepelumab-ekko) |
New |
|
August 8, 2022 |
*ING-CC-0086 |
Spravato (esketamine) Nasal Spray |
Revised |
|
August 8, 2022 |
ING-CC-0157 |
Padcev (enfortumab vedotin) |
Revised |
|
August 8, 2022 |
ING-CC-0125 |
Opdivo (nivolumab) |
Revised |
|
August 8, 2022 |
ING-CC-0119 |
Yervoy (ipilimumab) |
Revised |
|
August 8, 2022 |
*ING-CC-0099 |
Abraxane (paclitaxel, protein bound) |
Revised |
|
August 8, 2022 |
ING-CC-0120 |
Kyprolis (carfilzomib) |
Revised |
|
August 8, 2022 |
ING-CC-0126 |
Blincyto (blinatumomab) |
Revised |
|
August 8, 2022 |
ING-CC-0129 |
Bavencio (avelumab) |
Revised |
|
August 8, 2022 |
*ING-CC-0090 |
Ixempra (ixabepilone) |
Revised |
|
August 8, 2022 |
ING-CC-0110 |
Perjeta (pertuzumab) |
Revised |
|
August 8, 2022 |
ING-CC-0115 |
Kadcyla (ado-trastuzumab) |
Revised |
|
August 8, 2022 |
ING-CC-0108 |
Halaven (eribulin) |
Revised |
|
August 8, 2022 |
*ING-CC-0033 |
Xolair (omalizumab) |
Revised |
|
August 8, 2022 |
*ING-CC-0043 |
Monoclonal Antibodies to Interleukin-5 |
Revised |
|
August 8, 2022 |
ING-CC-0038 |
Human Parathyroid Hormone Agents |
Revised |
|
August 8, 2022 |
*ING-CC-0186 |
Margenza (margetuximab-cmkb) |
Revised |
|
August 8, 2022 |
*ING-CC-0124 |
Keytruda (pembrolizumab) |
Revised |
|
August 8, 2022 |
*ING-CC-0078 |
Orencia (abatacept) |
Revised |
|
August 8, 2022 |
ING-CC-0050 |
Monoclonal Antibodies to Interleukin-23 |
Revised |
|
August 8, 2022 |
ING-CC-0042 |
Monoclonal Antibodies to Interleukin-17 |
Revised |
|
August 8, 2022 |
*ING-CC-0029 |
Dupixent (dupilumab) |
Revised |
|
August 8, 2022 |
*ING-CC-0208 |
Adbry (tralokinumab) |
Revised |
|
August 8, 2022 |
*ING-CC-0209 |
Leqvio (inclisiran) |
Revised |
|
August 8, 2022 |
*ING-CC-0166 |
Trastuzumab Agents |
Revised |
|
August 8, 2022 |
*ING-CC-0107 |
Bevacizumab for Non-ophthalmologic Indications |
Revised |
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PUBLICATIONS: June 2022 Anthem Blue Cross Provider News - California
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