On August 20, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

New: newly published criteria

Revised: addition or removal of medical necessity requirements, new document number

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

 

Effective date

Document number

Clinical Criteria title

New or revised

March 24, 2022

ING-CC-0202*

Saphnelo (anifrolumab-fnia)

New

March 24, 2022

ING-CC-0010*

Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors

Revised

March 24, 2022

ING-CC-0034*

Hereditary Angioedema Agents

Revised

March 24, 2022

ING-CC-0027*

Denosumab Agents

Revised

March 24, 2022

ING-CC-0156*

Reblozyl (luspatercept)

Revised

March 24, 2022

ING-CC-0124

Keytruda (pembrolizumab)

Revised

March 24, 2022

ING-CC-0104*

Levoleucovorin Agents

Revised

March 24, 2022

ING-CC-0062

Tumor Necrosis Factor Antagonists  

Revised

March 24, 2022

ING-CC-0009*

Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis

Revised

March 24, 2022

ING-CC-0020

Tysabri (natalizumab)

Revised

March 24, 2022

ING-CC-0029*

Dupixent (dupilumab)

Revised

March 24, 2022

ING-CC-0038

Human Parathyroid Hormone Agents

Revised

March 24, 2022

ING-CC-0182*

Iron Agents

Revised

March 24, 2022

ING-CC-0075

Rituximab Agents for Non-Oncologic Indications

Revised

March 24, 2022

ING-CC-0096

Asparagine Specific Enzymes

Revised

March 24, 2022

ING-CC-0169

Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)

Revised

March 24, 2022

ING-CC-0193

Evkeeza (evinacumab)

Revised

March 24, 2022

ING-CC-0081*

Crysvita (burosumab-twza)

Revised

 

AIN-NU-0321-21



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March 2022 Anthem Provider News - Indiana