Medical drug benefit clinical criteria update

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following clinical criteria applicable to the medical drug benefit for Anthem and AMH Health, LLC. 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 would like 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 members of your practice and office staff.

 

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.

 

Effective date	Document number	Clinical Criteria title	New or revised
July 16, 2021	ING-CC-0195*	Abecma (idecabtagene vicleucel)	New
July 16, 2021	ING-CC-0191*	Pepaxto (melphalan flufenamide; melflufen)	New
July 16, 2021	ING-CC-0192*	Cosela (trilaciclib)	New
July 16, 2021	ING-CC-0193*	Evkeeza (evinacumab)	New
July 16, 2021	ING-CC-0194*	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	New
July 16, 2021	ING-CC-0125	Opdivo (nivolumab)	Revised
July 16, 2021	ING-CC-0064	Interleukin-1 Inhibitors	Revised
July 16, 2021	ING-CC-0159*	Scenesse (afamelanotide)	Revised
July 16, 2021	ING-CC-0151	Yescarta (axicabtagene ciloleucel)	Revised
July 16, 2021	ING-CC-0145*	Libtayo (cemiplimab-rwlc)	Revised
July 16, 2021	ING-CC-0130*	Imfinzi (durvalumab)	Revised
July 16, 2021	ING-CC-0127	Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)	Revised
July 16, 2021	ING-CC-0075*	Rituximab Agents for Non-Oncologic Indications	Revised

 

ABSCRNU-0233-21

AMHCRNU-0073-21