Policy UpdatesCommercialMay 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