Policy UpdatesMedicare AdvantageFebruary 14, 2025

Clinical Criteria updates

Effective March 24, 2025

Summary

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

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 plan. 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

May 24, 2025

CC-0272

Aucatzyl (obecabtagene autoleucel)

New

May 24, 2025

CC-0273

Vyloy (zolbetuximab-clzb)

New

May 24, 2025

CC-0223

Imjudo (tremelimumab-actl)

Revised

May 24, 2025

CC-0056

Selected Injectable 5HT3 Antiemetic Agents

Revised

May 24, 2025

CC-0148

Agents for Hemophilia B

Revised

May 24, 2025

CC-0149

Select Clotting Agents for Bleeding Disorders

Revised

May 24, 2025

CC-0065

Agents for Hemophilia A and von Willebrand Disease

Revised

May 24, 2025

CC-0124

Keytruda (pembrolizumab)

Revised

May 24, 2025

CC-0151

Yescarta (axicabtagene ciloleucel)

Revised

May 24, 2025

CC-0187

Breyanzi (lisocabtagene maraleucel)

Revised

May 24, 2025

CC-0204

Tivdak (tisotumab vedotin-tftv)

Revised

May 24, 2025

CC-0226

Elahere (mirvetuximab)

Revised

May 24, 2025

CC-0125

Opdivo (nivolumab)

Revised

May 24, 2025

CC-0128

Tecentriq (atezolizumab)

Revised

May 24, 2025

CC-0011

Ocrevus (ocrelizumab)/Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq)

Revised

May 24, 2025

CC-0173

Enspryng (satralizumab-mwge)

Revised

May 24, 2025

CC-0170

Uplizna (inebilizumab-cdon)

Revised

May 24, 2025

CC-0199

Empaveli (pegcetacoplan)

Revised

May 24, 2025

CC-0041

Complement Inhibitors

Revised

May 24, 2025

CC-0071

Entyvio (vedolizumab)

Revised

May 24, 2025

CC-0064

Interleukin-1 Inhibitors

Revised

May 24, 2025

CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

May 24, 2025

CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

May 24, 2025

CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

May 24, 2025

CC-0078

Orencia (abatacept)

Revised

May 24, 2025

CC-0063

Ustekinumab Agents

Revised

May 24, 2025

CC-0062

Tumor Necrosis Factor Antagonists

Revised

May 24, 2025

CC-0003

Immunoglobulins

Revised

May 24, 2025

CC-0073

Alpha-1 Proteinase Inhibitor Therapy

Revised

May 24, 2025

CC-0043

Monoclonal Antibodies to Interleukin-5

Revised

May 24, 2025

CC-0029

Dupixent (dupilumab)

Revised

May 24, 2025

CC-0105

Vectibix (panitumumab)

Revised

May 24, 2025

CC-0095

Bortezomib (Boruzu, Velcade)

Revised

May 24, 2025

CC-0161

Sarclisa (isatuximab-irfc)

Revised

May 24, 2025

CC-0201

Rybrevant (amivantamab-vmjw)

Revised

May 24, 2025

CC-0120

Kyprolis (carfilzomib)

Revised

May 24, 2025

CC-0197

Jemperli (dostarlimab-gxly)

Revised

May 24, 2025

CC-0255

Loqtorzi (toripalimab-tpzi)

Revised

May 24, 2025

CC-0002

Colony Stimulating Factor 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-075800-24-CPN74713

PUBLICATIONS: March 2025 Provider Newsletter