CommercialMay 1, 2024
Anthem Clinical Criteria updates for specialty pharmacy are available
Effective for dates of service on and after August 1, 2024, the following Clinical Criteria were developed and might result in services that were previously covered but may now be found to be not medically necessary.
Clinical Criteria | Medication |
CC-0033 | Xolair (omalizumab) |
CC-0088 | Elzonris (tagraxofusp-erzs) |
CC-0090 | Ixempra (ixabepilone) |
CC-0096 | Asparagine Specific Enzymes |
CC-0099 | Abraxane (paclitaxel, protein bound) |
CC-0112 | Xofigo (Radium Ra 223 Dichloride) |
CC-0115 | Kadcyla (ado-trastuzumab) |
CC-0123 | Cyramza (ramucirumab) |
CC-0125 | Opdivo (nivolumab) |
CC-0126 | Blincyto (blinatumomab) |
CC-0131 | Besponsa (inotuzumab ozogamicin) |
CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) |
CC-0258 | iDose TR (travoprost implant) |
Access the Clinical Criteria document information.
Anthem’s 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.
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-055621-24
PUBLICATIONS: May 2024 Provider Newsletter
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