Clinical Criteria updates

Medicare Advantage

 

On August 21, 2020, November 20, 2020, and June 24, 2021, the Pharmacy and Therapeutics (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 members of 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.

 

Effective date	Document number	Clinical Criteria title	New or revised
November 1, 2021	*ING-CC-0201	Rybrevant (amivantamab-vmjm)	New
November 1, 2021	*ING-CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
November 1, 2021	*ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
November 1, 2021	ING-CC-0125	Opdivo (nivolumab)	Revised
November 1, 2021	ING-CC-0124	Keytruda (pembrolizumab)	Revised
November 1, 2021	*ING-CC-0102	GnRH Analogs for Oncologic Indications	Revised
November 1, 2021	ING-CC-0076	Nulojix (belatacept)	Revised
November 1, 2021	*ING-CC-0077	Palynziq (pegvaliase-pqpz)	Revised
November 1, 2021	ING-CC-0067	Prostacyclin Infusion and Inhalation Therapy	Revised
November 1, 2021	ING-CC-0194	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	Revised

 

ABSCRNU-0261-21