Products & Programs PharmacyCommercialFebruary 1, 2024

Anthem Clinical Criteria updates for specialty pharmacy

Effective for dates of service on and after May 1, 2024, the following Clinical Criteria might result in services that were previously covered but may now be found to be not medically necessary:

Clinical Criteria

Description

CC-0002

Colony stimulating factor agents

CC-0032

Botulinum toxin

CC-0041

Complement inhibitors

CC-0042

Monoclonal antibodies to interleukin-17

CC-0068

Growth hormone

CC-0133

Aliqopa (copanlisib)

CC-0195

Abecma (idecabtagene vicleucel

CC-0199

Empaveli (pegcetacoplan)

CC-0214

Carvykti (ciltacabtagene autoleucel)

CC-0226

Elahere (mirvetuximab)

CC-0252

Adzynma (ADAMTS13, recombinant-krhn)

CC-0254

Zilbysq (zilucoplan)

Access the Clinical Criteria document information.

Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s Medical Specialty Drug Review team. Drugs used for the treatment of oncology will be managed by Carelon Medical Benefits Management, Inc., a separate company.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

GABCBS-CM-048149-23

PUBLICATIONS: February 2024 Provider Newsletter