Medicare AdvantageMay 11, 2023
Clinical Criteria Updates February 2023
This communication applies to the Medicare Advantage program from Anthem Blue Cross and Blue Shield (Anthem) in Connecticut.
Summary: On February 24, 2023, 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 | Document Number | Clinical Criteria Title | New or Revised |
August 17, 2023 | *CC-0232 | Lunsumio (mosunetuzumab-axgb) | New |
August 17, 2023 | *CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | New |
August 17, 2023 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | New |
August 17, 2023 | *CC-0234 | Syfovre (pegcetacoplan) | New |
August 17, 2023 | *CC-0231 | Lamzede (velmanase alfa-tycv) | New |
August 17, 2023 | CC-0007 | Synagis (palivizumab) | Revised |
August 17, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
August 17, 2023 | CC-0210 | Enjaymo (sutimlimab-jome) | Revised |
August 17, 2023 | *CC-0128 | Tecentriq (atezolizumab) | Revised |
August 17, 2023 | *CC-0116 | Bendamustine agents | Revised |
August 17, 2023 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
August 17, 2023 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
August 17, 2023 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
August 17, 2023 | *CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
August 17, 2023 | CC-0125 | Opdivo (nivolumab) | Revised |
August 17, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised |
August 17, 2023 | CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
August 17, 2023 | *CC-0093 | Docetaxel (Taxotere) | Revised |
August 17, 2023 | CC-0094 | Pemetrexed Agents (Alimta, Pemfexy) | Revised |
August 17, 2023 | CC-0130 | Imfinzi (durvalumab) | Revised |
August 17, 2023 | CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
August 17, 2023 | CC-0123 | Cyramza (ramucirumab) | Revised |
August 17, 2023 | CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
August 17, 2023 | CC-0121 | Gazyva (obinutuzumab) | Revised |
August 17, 2023 | *CC-0096 | Asparagine Specific Enzymes | Revised |
August 17, 2023 | *CC-0120 | Kyprolis (carfilzomib) | Revised |
August 17, 2023 | CC-0117 | Empliciti (elotuzumab) | Revised |
August 17, 2023 | CC-0126 | Blincyto (blinatumomab) | Revised |
August 17, 2023 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
August 17, 2023 | CC-0097 | Vidaza (azacitidine) | Revised |
August 17, 2023 | CC-0129 | Bavencio (avelumab) | Revised |
August 17, 2023 | CC-0090 | Ixempra (ixabepilone) | Revised |
August 17, 2023 | *CC-0110 | Perjeta (pertuzumab) | Revised |
August 17, 2023 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
August 17, 2023 | CC-0124 | Keytruda (pembrolizumab) | Revised |
August 17, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
August 17, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
CTBCBS-CR-024406-23-CPN24010
PUBLICATIONS: June 2023 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/connecticut/articles/clinical-criteria-updates-february-2023-4-13319
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