Policy UpdatesCommercialJune 1, 2025

Clinical Criteria updates for specialty pharmacy are now available

Effective for dates of service on and after September 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-0037

Kanuma (sebelipase alfa)

CC-0159

Scenesse (afamelanotide)

CC-0149

Select Clotting Agents for Bleeding Disorders

Access Clinical Criteria website for more information.

Anthem medical specialty drug review team 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-083214-25

PUBLICATIONS: June 2025 Provider Newsletter