On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following clinical criteria applicable to the medical drug benefit for Anthem and AMH Health, LLC. 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

July 16, 2021

ING-CC-0195*

Abecma (idecabtagene vicleucel)

New

July 16, 2021

ING-CC-0191*

Pepaxto (melphalan flufenamide; melflufen)

New

July 16, 2021

ING-CC-0192*

Cosela (trilaciclib)

New

July 16, 2021

ING-CC-0193*

Evkeeza (evinacumab)

New

July 16, 2021

ING-CC-0194*

Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

New

July 16, 2021

ING-CC-0125

Opdivo (nivolumab)

Revised

July 16, 2021

ING-CC-0064

Interleukin-1 Inhibitors

Revised

July 16, 2021

ING-CC-0159*

Scenesse (afamelanotide)

Revised

July 16, 2021

ING-CC-0151

Yescarta (axicabtagene ciloleucel)

Revised

July 16, 2021

ING-CC-0145*

Libtayo (cemiplimab-rwlc)

Revised

July 16, 2021

ING-CC-0130*

Imfinzi (durvalumab)

Revised

July 16, 2021

ING-CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

July 16, 2021

ING-CC-0075*

Rituximab Agents for Non-Oncologic Indications

Revised

 

ABSCRNU-0233-21

AMHCRNU-0073-21



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July 2021 Connecticut Provider News