Policy UpdatesMedicare AdvantageAugust 14, 2023

Clinical Criteria updates - May 2023

On December 22, 2022, May 2, 2023, and May 19, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (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 need 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

November 16, 2023

*CC-0237

Qalsody (tofersen) 

New

November 16, 2023

*CC-0238

Hydroxyprogesterone caproate 

New

November 16, 2023

*CC-0240

Zynyz (retifanlimab-dlwr) 

New

November 16, 2023

CC-0165

Trodelvy (sacituzumab govitecan)

Revised

November 16, 2023

CC-0002

Colony Stimulating Factor Agents

Revised

November 16, 2023

CC-0128

Tecentriq (atezolizumab)

Revised

November 16, 2023

CC-0098

Doxorubicin Liposome (Doxil, Lipodox)

Revised

November 16, 2023

CC-0101

Torisel (temsirolimus)

Revised

November 16, 2023

CC-0107

Bevacizumab for Non-Ophthalmologic Indications

Revised

November 16, 2023

CC-0143

Polivy (polatuzumab vedotin-piiq)

Revised

November 16, 2023

CC-0092

Adcetris (brentuximab vedotin)

Revised

November 16, 2023

CC-0095

Velcade (bortezomib)

Revised

November 16, 2023

CC-0105

Vectibix (panitumumab)

Revised

November 16, 2023

CC-0178

Synribo (omacetaxine mepesuccinate)

Revised

November 16, 2023

CC-0114

Jevtana (cabazitaxel)

Revised

November 16, 2023

CC-0145

Libtayo (cemiplimab-rwlc)

Revised

November 16, 2023

*CC-0032

Botulinum Toxin

Revised

November 16, 2023

CC-0068

Growth Hormone

Revised

November 16, 2023

*CC-0057

Krystexxa (pegloticase)

Revised

November 16, 2023

*CC-0125

Opdivo (nivolumab) 

Revised

November 16, 2023

*CC-0225

Tzield (teplizumab-mzwv)

Revised

November 16, 2023

*CC-0124

Keytruda (pembrolizumab)

Revised

CTBCBS-CR-031947-23-CPN30755

PUBLICATIONS: September 2023 Provider Newsletter