MedicaidJuly 28, 2023
Clinical Criteria updates - November 2022
Summary
On September 12, 2022, and November 18, 2022, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Medicaid (Anthem). 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 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 | Document number | Clinical Criteria title | New or revised |
September 10, 2023 | *CC-0222 | Tecvayli (teclistamab-cqyv) | New |
September 10, 2023 | *CC-0223 | Imjudo (tremelimumab-actl) | New |
September 10, 2023 | *CC-0224 | Pedmark (sodium thiosulfate injection) | New |
September 10, 2023 | *CC-0225 | Tzield (teplizumab) | New |
September 10, 2023 | CC-0130 | Imfinzi (durvalumab) | Revised |
September 10, 2023 | *CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
September 10, 2023 | CC-0148 | Agents for Hemophilia B | Revised |
September 10, 2023 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised |
September 10, 2023 | CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
September 10, 2023 | *CC-0124 | Keytruda (pembrolizumab) | Revised |
September 10, 2023 | *CC-0168 | Tecartus (brexucabtagene autoleucel) | Revised |
September 10, 2023 | *CC-0195 | Abecma (idecabtagene vicleucel) | Revised |
September 10, 2023 | *CC-0150 | Kymriah (tisagenlecleucel) | Revised |
September 10, 2023 | *CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised |
September 10, 2023 | *CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
September 10, 2023 | *CC-0214 | Carvykti (ciltacabtagene autoleucel) | Revised |
September 10, 2023 | CC-0133 | Aliqopa (copanlisib) | Revised |
September 10, 2023 | *CC-0041 | Complement Inhibitors | Revised |
September 10, 2023 | *CC-0071 | Entyvio (vedolizumab) | Revised |
September 10, 2023 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
September 10, 2023 | *CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
September 10, 2023 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
September 10, 2023 | *CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
September 10, 2023 | *CC-0078 | Orencia (abatacept) | Revised |
September 10, 2023 | *CC-0063 | Stelara (ustekinumab) | Revised |
September 10, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
September 10, 2023 | *CC-0003 | Immunoglobulins | Revised |
September 10, 2023 | CC-0072 | Selective Vascular Endothelial Growth Factor (VEGF) Antagonists | Revised |
September 10, 2023 | *CC-0100 | Istodax (romidepsin) | Revised |
September 10, 2023 | *CC-0204 | Tivdak (tisotumab vedotin-tftv) | Revised |
September 10, 2023 | *CC-0205 | Fyarro (siroliumus albumin bound) | Revised |
September 10, 2023 | *CC-0182 | Iron Agents | Revised |
KYBCBS-CD-018991-23-CPN18398
PUBLICATIONS: September 2023 Provider Newsletter
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Visit https://providernews.anthem.com/kentucky/articles/clinical-criteria-updates-61-14807
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