MedicaidNovember 21, 2024
Clinical Criteria update
Effective December 22, 2024
Summary: On May 17, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.
Visit https://anthem.com/ms/pharmacyinformation/clinicalcriteria/home.html to search for specific policies. For questions or 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 providers in 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.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised |
December 22, 2024 | *CC-0262 | Tevimbra (tislelizumab-jsgr) | New |
December 22, 2024 | *CC-0162 | Tepezza (teprotumumab-trbw) | Revised |
December 22, 2024 | *CC-0111 | Nplate (romiplostim) | Revised |
December 22, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
December 22, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
December 22, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
December 22, 2024 | *CC-0098 | Doxorubicin Liposome (Doxil, Lipodox) | Revised |
December 22, 2024 | *CC-0101 | Torisel (temsirolimus) | Revised |
December 22, 2024 | *CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
December 22, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
December 22, 2024 | *CC-0092 | Adcetris (brentuximab vedotin) | Revised |
December 22, 2024 | CC-0106 | Erbitux (cetuximab) | Revised |
December 22, 2024 | *CC-0105 | Vectibix (panitumumab) | Revised |
December 22, 2024 | CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
December 22, 2024 | CC-0160 | Vyepti (eptinezumab) | Revised |
December 22, 2024 | CC-0102 | GNRH Analogs for Oncologic Indications | Revised |
December 22, 2024 | CC-0201 | Rybrevant (amivantamab-ymjw) | Revised |
December 22, 2024 | *CC-0188 | Imcivree (setmelanotide) | Revised |
December 22, 2024 | *CC-0124 | Keytruda (pembrolizumab) | Revised |
December 22, 2024 | CC-0041 | Complement C5 Inhibitors | Revised |
December 22, 2024 | CC-0199 | Empaveli (pegcetacoplan) | Revised |
December 22, 2024 | *CC-0130 | Imfinzi (durvalumab) | Revised |
December 22, 2024 | CC-0240 | Zynyz (retifanlimab-dlwr) | Revised |
December 22, 2024 | CC-0123 | Cyramza (ramucirumab) | Revised |
December 22, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
December 22, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
December 22, 2024 | CC-0226 | Elahere (mirvetuximab) | Revised |
December 22, 2024 | CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
December 22, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
December 22, 2024 | CC-0221 | Spevigo (spesolimab-sbzo) | Revised |
December 22, 2024 | CC-0071 | Entyvio (vedolizumab) | Revised |
December 22, 2024 | *CC-0063 | Ustekinumab Agents | Revised |
Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
KYBCBS-CD-063663-24-CPN63281
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Visit https://providernews.anthem.com/kentucky/articles/clinical-criteria-update-23156
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