Medicare AdvantageJuly 10, 2024
Clinical Criteria updates
Effective October 12, 2024
Summary: On May 17, 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. If you have questions or for 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 |
October 12, 2024 | *CC-0262 | Tevimbra (tislelizumab-jsgr) | New |
October 12, 2024 | *CC-0162 | Tepezza (teprotumumab-trbw) | Revised |
October 12, 2024 | *CC-0111 | Nplate (romiplostim) | Revised |
October 12, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
October 12, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
October 12, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
October 12, 2024 | *CC-0098 | Doxorubicin Liposome (Doxil, Lipodox) | Revised |
October 12, 2024 | *CC-0101 | Torisel (temsirolimus) | Revised |
October 12, 2024 | *CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
October 12, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
October 12, 2024 | *CC-0092 | Adcetris (brentuximab vedotin) | Revised |
October 12, 2024 | CC-0106 | Erbitux (cetuximab) | Revised |
October 12, 2024 | *CC-0105 | Vectibix (panitumumab) | Revised |
October 12, 2024 | CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
October 12, 2024 | CC-0160 | Vyepti (eptinezumab) | Revised |
October 12, 2024 | CC-0102 | GNRH Analogs for Oncologic Indications | Revised |
October 12, 2024 | CC-0201 | Rybrevant (amivantamab-ymjw) | Revised |
October 12, 2024 | *CC-0188 | Imcivree (setmelanotide) | Revised |
October 12, 2024 | *CC-0124 | Keytruda (pembrolizumab) | Revised |
October 12, 2024 | CC-0041 | Complement C5 Inhibitors | Revised |
October 12, 2024 | CC-0199 | Empaveli (pegcetacoplan) | Revised |
October 12, 2024 | *CC-0130 | Imfinzi (durvalumab) | Revised |
October 12, 2024 | CC-0240 | Zynyz (retifanlimab-dlwr) | Revised |
October 12, 2024 | CC-0123 | Cyramza (ramucirumab) | Revised |
October 12, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
October 12, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
October 12, 2024 | CC-0226 | Elahere (mirvetuximab) | Revised |
October 12, 2024 | CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
October 12, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
October 12, 2024 | CC-0221 | Spevigo (spesolimab-sbzo) | Revised |
October 12, 2024 | CC-0071 | Entyvio (vedolizumab) | Revised |
October 12, 2024 | *CC-0063 | Ustekinumab Agents | 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-061713-24-CPN61521
PUBLICATIONS: August 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/connecticut/articles/clinical-criteria-updates-20793
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