Products & Programs PharmacyCommercialMay 1, 2025

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the Clinical Criteria meeting on December 18, 2024. Visit our Clinical Criteria In Pharmacy page to access the Clinical Criteria information.

New Clinical Criteria effective August 1, 2025

  • CC-0275 Ziihera (zanidatamab‑hrii)
  • CC‑0276 Tryngolza (olezarsen)
  • CC‑0277 Vyalev (foscarbidopa/foslevodopa)

Revised Clinical Criteria effective August 1, 2025

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

  • CC‑0058 Octreotide Agents
  • CC‑0063 Ustekinumab Agents (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Wezlana)
  • CC‑0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
  • CC‑0094 Pemetrexed (Alimta, Axtle, Pemfexy, Pemrydi)
  • CC‑0130 Imfinzi (durvalumab)
  • CC‑0185 Oxlumo (lumasiran)
  • CC‑0256 Rivfloza (nedosiran)

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PUBLICATIONS: May 2025 Provider Newsletter