Products & Programs PharmacyCommercialOctober 31, 2023

Clinical Criteria updates for specialty pharmacy are available (MAC)

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

Clinical Criteria

Description

CC-0041

Complement Inhibitors

CC-0119

Yervoy (ipilimumab)

CC-0125

Opdivo (nivolumab)

CC-0193

Evkeeza (evinacumab)

CC-0197

Jemperli (dostarlimab-gxly)

CC-0207

Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)

CC-0243

Vyjuvek (beremagene geperpavec)

CC-0247

Beyfortus (nirsevimab)

Access the Clinical Criteria document information.

The prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by the medical specialty drug review team of Anthem Blue Cross and Blue Shield. 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.

GABCBS-CM-040850-23

PUBLICATIONS: November 2023 Provider Newsletter