Products & Programs PharmacyCommercialAugust 1, 2024

Clinical Criteria updates for specialty pharmacy are available

Effective for dates of service on and after November 1, 2024, the following Clinical Criteria were developed and might result in services that were previously covered but may now no longer be identified as medically necessary.

Clinical Criteria

Description

CC-0092

Adcetris (brentuximab vedotin)

CC-0098

Doxorubicin Liposome (Doxil, Lipodox)

CC-0105

Vectibix (panitumumab)

CC-0106

Erbitux (cetuximab)

CC-0107

Bevacizumab for Non-Ophthalmologic Indications

CC-0111

Nplate (romiplostim)

CC-0130

Imfinzi (durvalumab)

CC-0145

Libtayo (cemiplimab-rwlc)

CC-0162

Tepezza (teprotumumab-trbw)

Access the Clinical Criteria information online.

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.

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-062462-24

PUBLICATIONS: August 2024 Provider Newsletter