Medicare AdvantageJune 3, 2025
Clinical Criteria updates
Summary: The Pharmacy and Therapeutics (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 | Status |
September 4, 2025 | CC-0278 | Unloxcyt (cosibelimab-ipdl) | New |
September 4, 2025 | CC-0279 | Datroway (datopotamab deruxtecan-dlnk) | New |
September 4, 2025 | CC-0280 | Grafapex (treosulfan) | New |
September 4, 2025 | CC-0281 | Opdivo Qvantig (nivolumab hyaluronidase-nvhy) | New |
September 4, 2025 | CC-0128 | Atezolizumab (Tecentriq, Tecentriq Hybreza) | Revised |
September 4, 2025 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
September 4, 2025 | CC-0125 | Opdivo (nivolumab) | Revised |
September 4, 2025 | CC-0119 | Yervoy (ipilimumab) | Revised |
September 4, 2025 | CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
September 4, 2025 | CC-0093 | Docetaxel (Docivyx) | Revised |
September 4, 2025 | CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
September 4, 2025 | CC-0123 | Cyramza (ramucirumab) | Revised |
September 4, 2025 | CC-0121 | Gazyva (obinutuzumab) | Revised |
September 4, 2025 | CC-0122 | Arzerra (ofatumumab) | Revised |
September 4, 2025 | CC-0232 | Lunsumio (mosunetuzumab-axgb) | Revised |
September 4, 2025 | CC-0109 | Zaltrap (ziv-aflibercept) | Revised |
September 4, 2025 | CC-0135 | Melanoma Vaccines | Revised |
September 4, 2025 | CC-0126 | Blincyto (blinatumomab) | Revised |
September 4, 2025 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
September 4, 2025 | CC-0097 | Vidaza (azacitidine) | Revised |
September 4, 2025 | CC-0129 | Bavencio (avelumab) | Revised |
September 4, 2025 | CC-0110 | Perjeta (pertuzumab) | Revised |
September 4, 2025 | CC-0108 | Halaven (eribulin) | Revised |
September 4, 2025 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised |
September 4, 2025 | CC-0262 | Tevimbra (tislelizumab-jsgr) | Revised |
September 4, 2025 | CC-0061 | Gonadotropin Releasing Hormone (GnRH) Analogs for the Treatment of Non-Oncologic | Revised |
September 4, 2025 | CC-0026 | Testosterone Injectable | Revised |
September 4, 2025 | CC-0008 | Subcutaneous Hormonal Implants | Revised |
September 4, 2025 | CC-0015 | Infertility and HCG Agents | Revised |
September 4, 2025 | CC-0033 | Xolair (omalizumab) | Revised |
September 4, 2025 | CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
September 4, 2025 | CC-0029 | Dupixent (dupilumab) | Revised |
September 4, 2025 | CC-0269 | Nemluvio (nemolizumab-ilto) | Revised |
September 4, 2025 | CC-0267 | Ebglyss (lebrikizumab-lbkz) | Revised |
September 4, 2025 | CC-0208 | Adbry (tralokinumab) | Revised |
September 4, 2025 | CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
September 4, 2025 | CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
September 4, 2025 | CC-0063 | Ustekinumab Agents (Stelara, Selarsdi, Imuldosa, Pyzchiva, Otulfi, Steqeyma, Wezlana, Yesintek) | Revised |
September 4, 2025 | CC-0261 | Winrevair (sotatercept-csrk) | Revised |
September 4, 2025 | CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
September 4, 2025 | CC-0209 | Leqvio (inclisiran) | Revised |
September 4, 2025 | CC-0002 | Colony Stimulating Factor Agents | Revised |
September 4, 2025 | CC-0003 | Immunoglobulins | 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.
CPN81379, CTBCBS-CR-082348-25
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Visit https://providernews.anthem.com/connecticut/articles/clinical-criteria-updates-25536
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