CommercialMay 1, 2025
Clinical Criteria updates for specialty pharmacy are available
Effective for dates of service on and after August 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.
Document number |
Clinical Criteria |
CC‑0029 |
Dupixent (dupilumab) |
CC‑0269 |
Nemluvio (nemolizumab‑ilto) |
CC‑0122 |
Arzerra (ofatumumab) |
CC‑0128 |
Atezolizumab (Tecentriq, Tecentriq Hybreza) |
CC‑0158 |
Enhertu (fam‑trastuzumab deruxtecan‑nxki) |
CC‑0121 |
Gazyva (obinutuzumab) |
CC‑0061 |
Gonadotropin Releasing Hormone Analogs for the Treatment of Non‑Oncologic Indications |
CC‑0125 |
Opdivo (nivolumab) |
CC‑0008 |
Subcutaneous Hormonal Implants |
CC‑0261 |
Winrevair (sotatercept‑csrk) |
Access Clinical Criteria.
Our preapproval clinical review of non‑oncology specialty pharmacy drugs will be managed by our medical specialty drug review team. Drugs used for the treatment of Oncology will be managed by Carelon Medical Benefits Management, Inc.
CarelonRx, Inc. is an independent company providing pharmacy benefit 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-080579-25
PUBLICATIONS: May 2025 Provider Newsletter
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