Products & Programs PharmacyCommercialNovember 1, 2024

Clinical Criteria updates for specialty pharmacy are available

Effective for dates of service on and after February 1, 2025, 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.

CC-0007

Synagis (palivizumab)

CC-0028

Benlysta (belimumab)

CC-0029

Dupixent (dupilumab)

CC-0034

Hereditary Angioedema Agents

CC-0048

Spinraza (nusinersen)

CC-0058

Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents

CC-0096

Asparagine Specific Enzymes

CC-0156

Reblozyl (luspatercept)

CC-0194

Cabenuva (cabotegravir extended-release; rilpivirine extended -release) injection

Access Clinical Criteria document information for more details.

The Medical Specialty Drug Review team for Anthem will manage prior authorization clinical review of non-oncology specialty pharmacy drugs. 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-069583-24

PUBLICATIONS: November 2024 Provider Newsletter