Policy UpdatesMedicare AdvantageJune 4, 2024

Clinical Criteria updates

Effective September 5, 2024

Summary

On November 17, 2023, and March 21, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or 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 providers in 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.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date

Clinical Criteria number

Clinical Criteria title

New or revised

September 5, 2024

*CC-0261

Winrevair (sotatercept-csrk)

New

September 5, 2024

*CC-0125

Opdivo (nivolumab)

Revised

September 5, 2024

*CC-0003

Immunoglobulins

Revised

September 5, 2024

CC-0033

Xolair (omalizumab)

Revised

September 5, 2024

*CC-0062

Tumor Necrosis Factor Antagonists

Revised

September 5, 2024

CC-0121

Gazyva (obinutuzumab)

Revised

September 5, 2024

CC-0201

Rybrevant (amivantamab-ymjw)

Revised

September 5, 2024

*CC-0251

Ycanth (cantharidin)

Revised

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CR-059943-24-CPN59599

PUBLICATIONS: July 2024 Provider Newsletter