Products & Programs PharmacyCommercialMarch 1, 2025

Clinical Criteria updates for specialty pharmacy are available

Updates

Effective for dates of service on and after June 1, 2025, the following Clinical Criteria will apply. Services that were previously covered may now be found not medically necessary.

Prior authorization

Prior authorization of these specialty pharmacy drugs will be managed by the health plan’s medical specialty drug review team except where the drug is used for oncology treatment. Oncology drugs require prior authorization by Carelon Medical Benefits Management, Inc.

Access additional Clinical Criteria information here.

Document number

Description

CC‑0130

Imfinzi (durvalumab)

CC‑0058

Octreotide Agents

CC‑0185

Oxlumo (lumasiran)

CC‑0256

Rivfloza (nedosiran)

CC‑0276

Tryngolza (olezarsen)

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-077847-25

PUBLICATIONS: March 2025 Provider Newsletter