Policy UpdatesMedicaidNovember 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

PUBLICATIONS: December 2024 Provider Newsletter