Policy UpdatesMedicare AdvantageJune 3, 2024

Clinical Criteria updates — November 2023

Summary: On February 24, 2023, September 11, 2023, and November 17, 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

Clinical Criteria Number

Clinical Criteria Title

New or Revised

September 5, 2024

*CC-0252

Adzynma (ADAMTS13, recombinant-krhn)

New

September 5, 2024

*CC-0253

Aphexda (motixafortide)

New

September 5, 2024

*CC-0254

Zilbysq (zilucoplan)

New

September 5, 2024

CC-0130

Imfinzi (durvalumab)

Revised

September 5, 2024

CC-0223

Imjudo (tremelimumab-actl)

Revised

September 5, 2024

*CC-0059

Selected Injectable NK-1 Antiemetic Agents

Revised

September 5, 2024

CC-0074

Akynzeo (fosnetupitant and palonosetron) for injection

Revised

September 5, 2024

*CC-0065

Agents for Hemophilia A and von Willebrand Disease

Revised

September 5, 2024

CC-0124

Keytruda (pembrolizumab)

Revised

September 5, 2024

CC-0150

Kymriah (tisagenlecleucel)

Revised

September 5, 2024

CC-0187

Breyanzi (lisocabtagene maraleucel)

Revised

September 5, 2024

CC-0133

Aliqopa (copanlisib)

Revised

September 5, 2024

CC-0205

Fyarro (sirolimus albumin bound)

Revised

September 5, 2024

CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

September 5, 2024

*CC-0226

Elahere (mirvetuximab)

Revised

September 5, 2024

CC-0125

Opdivo (nivolumab)

Revised

September 5, 2024

CC-0058

Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents

Revised

September 5, 2024

*CC-0009

Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis

Revised

September 5, 2024

*CC-0014

Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

Revised

September 5, 2024

*CC-0011

Ocrevus (ocrelizumab)

Revised

September 5, 2024

*CC-0174

Kesimpta (ofatumumab)

Revised

September 5, 2024

*CC-0020

Natalizumab Agents (Tysabri, Tyruko)

Revised

September 5, 2024

*CC-0032

Botulinum Toxin

Revised

September 5, 2024

*CC-0068

Growth Hormone

Revised

September 5, 2024

*CC-0173

Enspryng (satralizumab-mwge)

Revised

September 5, 2024

*CC-0170

Uplizna (inebilizumab-cdon)

Revised

September 5, 2024

*CC-0199

Empaveli (pegcetacoplan)

Revised

September 5, 2024

*CC-0041

Complement Inhibitors

Revised

September 5, 2024

*CC-0071

Entyvio (vedolizumab)

Revised

September 5, 2024

*CC-0064

Interleukin-1 Inhibitors

Revised

September 5, 2024

*CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

September 5, 2024

*CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

September 5, 2024

*CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

September 5, 2024

*CC-0078

Orencia (abatacept)

Revised

September 5, 2024

*CC-0063

Ustekinumab Agents

Revised

September 5, 2024

*CC-0062

Tumor Necrosis Factor Antagonists

Revised

September 5, 2024

CC-0003

Immunoglobulins

Revised

September 5, 2024

*CC-0002

Colony Stimulating Factor Agents

Revised

September 5, 2024

CC-0247

Beyfortus (nirsevimab)

Revised

September 5, 2024

CC-0072

Vascular Endothelial Growth Factor (VEGF) Inhibitors

Revised

September 5, 2024

CC-0010

Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors

Revised

September 5, 2024

CC-0209

Leqvio (inclisiran)

Revised

September 5, 2024

*CC-0182

Iron Agents

Revised

September 5, 2024

*CC-0086

Spravato (esketamine) Nasal Spray

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-050488-24-CPN49884

PUBLICATIONS: July 2024 Provider Newsletter