Medicare AdvantageOctober 30, 2024
Clinical Criteria updates
Effective December 2, 2024
Summary: On August 16, 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 Clinical Criteria 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 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.
- 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 2, 2024 |
*CC-0266 |
Rytelo (imetelstat) |
New |
December 2, 2024 |
CC-0156 |
Reblozyl (luspatercept) |
Revised
|
December 2, 2024 |
CC-0244 |
Columvi (glofitamab-gxbm) |
Revised |
December 2, 2024 |
CC-0124 |
Keytruda (pembrolizumab) |
Revised |
December 2, 2024 |
CC-0104 |
Levoleucovorin Agents |
Revised |
December 2, 2024 |
CC-0182 |
Iron Agents |
Revised |
December 2, 2024 |
CC-0197 |
Jemperli (dostarlimab-gxly) |
Revised |
December 2, 2024 |
CC-0247 |
Beyfortus (nirsevimab) |
Revised |
December 2, 2024 |
*CC-0007 |
Synagis (palivizumab) |
Revised |
December 2, 2024 |
*CC-0082 |
Onpattro (patisiran) |
Revised |
December 2, 2024 |
*CC-0217 |
Amvuttra (vulrisiran) |
Revised |
December 2, 2024 |
*CC-0084 |
Tegsedi (inotersen) |
Revised |
December 2, 2024 |
*CC-0010 |
Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors |
Revised |
December 2, 2024 |
CC-0209 |
Leqvio (inclisiran) |
Revised |
December 2, 2024 |
*CC-0193 |
Evkeeza (evinacumab) |
Revised |
December 2, 2024 |
*CC-0027 |
Denosumab |
Revised |
December 2, 2024 |
CC-0019 |
Zoledronic Acid |
Revised |
December 2, 2024 |
CC-0208 |
Adbry (tralokinumab) |
Revised |
December 2, 2024 |
*CC-0029 |
Dupixent (dupilumab) |
Revised |
December 2, 2024 |
*CC-0246 |
Rystiggo (rozanolixizumab-noli) |
Revised |
December 2, 2024 |
*CC-0207 |
Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) |
Revised |
December 2, 2024 |
*CC-0028 |
Benlysta (belimumab) |
Revised |
December 2, 2024 |
*CC-0194 |
Cabenuva (cabotegravir extended-release; rilpivirine extended -release) injection |
Revised |
December 2, 2024 |
*CC-0002 |
Colony Stimulating Factor Agents |
Revised |
December 2, 2024 |
CC-0127 |
Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) |
Revised |
December 2, 2024 |
CC-0121 |
Gazyva (obinutuzumab) |
Revised |
December 2, 2024 |
CC-0242 |
Epkinly (epcoritamab-bysp) |
Revised |
December 2, 2024 |
CC-0130 |
Imfinzi (durvalumab) |
Revised |
December 2, 2024 |
CC-0158 |
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Revised |
December 2, 2024 |
CC-0050 |
Monoclonal Antibodies to Interleukin-23 |
Revised |
December 2, 2024 |
CC-0066 |
Monoclonal Antibodies to Interleukin-6 |
Revised |
December 2, 2024 |
CC-0071 |
Entyvio (vedolizumab) |
Revised |
December 2, 2024 |
*CC-0048 |
Spinraza (nusinersen) |
Revised |
December 2, 2024 |
*CC-0003 |
Immunoglobulins |
Revised |
December 2, 2024 |
*CC-0058 |
Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents |
Revised |
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CR-069101-24-CPN68761
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