MedicaidMay 2, 2024
Clinical Criteria updates — August 2023
On May 19, 2023, August 18, 2023, and August 30, 2023, 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 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 |
June 7, 2024 | *CC-0244 | Columvi (glofitamab-gxbm) | New |
June 7, 2024 | *CC-0245 | Izervay (avacincaptad pegol) | New |
June 7, 2024 | *CC-0246 | Rystiggo (rozanolixizumab-noli) | New |
June 7, 2024 | *CC-0247 | Beyfortus (nirsevimab) | New |
June 7, 2024 | CC-0001 | Erythropoiesis Stimulating Agents | Revised |
June 7, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
June 7, 2024 | CC-0104 | Levoleucovorin Agents | Revised |
June 7, 2024 | CC-0100 | Romidepsin | Revised |
June 7, 2024 | *CC-0182 | Iron Agents | Revised |
June 7, 2024 | CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised |
June 7, 2024 | CC-0176 | Beleodaq (belinostat) | Revised |
June 7, 2024 | CC-0180 | Monjuvi (tafasitamab-cxix) | Revised |
June 7, 2024 | CC-0107 | Bevacizumab for non-ophthalmologic indications | Revised |
June 7, 2024 | CC-0216 | Opdualag (nivolumab and relatlimab-rmbw) | Revised |
June 7, 2024 | CC-0196 | Zynlonta (loncastuximab tesirine-lpyl) | Revised |
June 7, 2024 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
June 7, 2024 | CC-0203 | Ryplazim (plasminogen, human-tvmh) | Revised |
June 7, 2024 | CC-0193 | Evkeeza (evinacumab) | Revised |
June 7, 2024 | *CC-0034 | Hereditary Angioedema Agents | Revised |
June 7, 2024 | *CC-0041 | Complement Inhibitors | Revised |
June 7, 2024 | *CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised |
June 7, 2024 | CC-0028 | Benlysta (belimumab) | Revised |
June 7, 2024 | *CC-0243 | Vyjuvek (beremagene geperpavec) | Revised |
June 7, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
June 7, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised |
June 7, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised |
June 7, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
June 7, 2024 | *CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
June 7, 2024 | *CC-0002 | Colony Stimulating Factor 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-051199-24-CPN44139
PUBLICATIONS: June 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/kentucky/articles/clinical-criteria-updates-august-2023-19494
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