Oct 1, 2022 • State & Federal / Medicaid

On September 22, 2021, and November 19, 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 Medicaid. 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.

 

Please 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

Sept. 16, 2022

*ING-CC-0204

Tivdak (tisotumab vedotin-tftv)

New

Sept. 16, 2022

*ING-CC-0018

Lumizyme (alglucosidase alfa); Nexviazyme (avalglucosidase alfa-ngpf)

Revised

Sept. 16, 2022

*ING-CC-0128

Tecentriq (atezolizumab)

Revised

Sept. 16, 2022

*ING-CC-0012

Brineura (cerliponase alfa)

Revised

Sept. 16, 2022

*ING-CC-0021

Fabrazyme (agalsidase beta)

Revised

Sept. 16, 2022

*ING-CC-0017

Xiaflex (collagenase clostridium histolyticum)

Revised

Sept. 16, 2022

*ING-CC-0026

Testosterone Injectable

Revised

Sept. 16, 2022

*ING-CC-0100

Istodax (romidepsin)

Revised

Sept. 16, 2022

*ING-CC-0125

Opdivo (nivolumab)

Revised

Sept. 16, 2022

ING-CC-0197

Jemperli (dostarlimab-gxly)

Revised

Sept. 16, 2022

ING-CC-0124

Keytruda (pembrolizumab)

Revised

Sept. 16, 2022

*ING-CC-0061

GnRH Analogs for the Treatment of Non-Oncologic Indications

Revised

Sept. 16, 2022

*ING-CC-0148

Agents for Hemophilia B

Revised

Sept. 16, 2022

*ING-CC-0149

Select Clotting Agents for Bleeding Disorders

Revised

Sept. 16, 2022

*ING-CC-0065

Agents for Hemophilia A and von Willebrand Disease

Revised

Sept. 16, 2022

ING-CC-0168

Tecartus (brexucabtagene autoleucel)

Revised

Sept. 16, 2022

*ING-CC-0195

Abecma (idecabtagene vicleucel)

Revised

Sept. 16, 2022

*ING-CC-0001

Erythropoiesis Stimulating Agents

Revised

Sept. 16, 2022

*ING-CC-0173

Enspryng (satralizumab-mwge)

Revised

Sept. 16, 2022

*ING-CC-0170

Uplizna (inebilizumab-cdon)

Revised

Sept. 16, 2022

*ING-CC-0041

Complement Inhibitors

Revised

Sept. 16, 2022

*ING-CC-0071

Entyvio (vedolizumab)

Revised

Sept. 16, 2022

*ING-CC-0064

Interleukin-1 Inhibitors

Revised

Sept. 16, 2022

*ING-CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

Sept. 16, 2022

*ING-CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

Sept. 16, 2022

*ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

Sept. 16, 2022

*ING-CC-0078

Orencia (abatacept)

Revised

Sept. 16, 2022

*ING-CC-0063

Stelara (ustekinumab)

Revised

Sept. 16, 2022

*ING-CC-0062

Tumor Necrosis Factor Antagonists

Revised

Sept. 16, 2022

ING-CC-0003

Immunoglobulins

Revised

Sept. 16, 2022

*ING-CC-0049

Radicava (edaravone)

Revised

Sept. 16, 2022

*ING-CC-0075

Rituximab Agents for Non-Oncologic Indications

Revised

Sept. 16, 2022

*ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Revised

Sept. 16, 2022

ING-CC-0107

Bevacizumab for Non-Ophthalmologic Indications

Revised

Sept. 16, 2022

ING-CC-0106

Erbitux (cetuximab)

Revised

Sept. 16, 2022

ING-CC-0105

Vectibix (panitumumab)

Revised

Sept. 16, 2022

ING-CC-0043

Monoclonal Antibodies to Interleukin-5

Revised

Sept. 16, 2022

*ING-CC-0068

Growth Hormone

Revised

 

AKY-NU-0381-22


Featured In:
October 2022 Anthem Provider News - Kentucky