MedicaidJune 5, 2024
Clinical Criteria updates
Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 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. If you have questions or need 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 |
July 7, 2024 | *CC-0258 | iDoseTR (travoprost Implant) | New |
July 7, 2024 | *CC-0259 | Amtagvi (lifleucel) | New |
July 7, 2024 | *CC-0260 | Nexobrid (anacaulase-bcdb) | New |
July 7, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
July 7, 2024 | *CC-0041 | Complement Inhibitors | Revised |
July 7, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
July 7, 2024 | CC-0116 | Bendamustine agents | Revised |
July 7, 2024 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
July 7, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
July 7, 2024 | CC-0157 | Padcev (enfortumab vedotin) | Revised |
July 7, 2024 | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | Revised |
July 7, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised |
July 7, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised |
July 7, 2024 | *CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
July 7, 2024 | *CC-0093 | Docetaxel (Taxotere) | Revised |
July 7, 2024 | *CC-0094 | Pemetrexed (Alimta, Pemfexy, Pemrydi) | Revised |
July 7, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
July 7, 2024 | *CC-0088 | Elzonris (tagraxofusp-erzs) | Revised |
July 7, 2024 | *CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
July 7, 2024 | *CC-0112 | Xofigo (Radium Ra 223 Dichloride) | Revised |
July 7, 2024 | *CC-0123 | Cyramza (ramucirumab) | Revised |
July 7, 2024 | *CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
July 7, 2024 | CC-0121 | Gazyva (obinutuzumab) | Revised |
July 7, 2024 | CC-0122 | Arzerra (ofatumumab) | Revised |
July 7, 2024 | CC-0232 | Lunsumio (mosunetuzumab-axgb) | Revised |
July 7, 2024 | CC-0109 | Zaltrap (ziv-aflibercept) | Revised |
July 7, 2024 | CC-0135 | Melanoma Vaccines | Revised |
July 7, 2024 | *CC-0096 | Asparagine Specific Enzymes | Revised |
July 7, 2024 | CC-0120 | Kyprolis (carfilzomib) | Revised |
July 7, 2024 | *CC-0117 | Empliciti (elotuzumab) | Revised |
July 7, 2024 | *CC-0126 | Blincyto (blinatumomab) | Revised |
July 7, 2024 | CC-0113 | Sylvant (siltuximab) | Revised |
July 7, 2024 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
July 7, 2024 | CC-0097 | Vidaza (azacitidine) | Revised |
July 7, 2024 | CC-0129 | Bavencio (avelumab) | Revised |
July 7, 2024 | *CC-0090 | Ixempra (ixabepilone) | Revised |
July 7, 2024 | CC-0110 | Perjeta (pertuzumab) | Revised |
July 7, 2024 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
July 7, 2024 | *CC-0108 | Halaven (eribulin) | Revised |
July 7, 2024 | CC-0089 | Mozobil (plerixafor) | Revised |
July 7, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
July 7, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
July 7, 2024 | *CC-0212 | Tezspire (tezepelumab-ekko) | Revised |
July 7, 2024 | *CC-0033 | Xolair (omalizumab) | Revised |
July 7, 2024 | *CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
July 7, 2024 | *CC-0029 | Dupixent (dupilumab) | Revised |
July 7, 2024 | *CC-0208 | Adbry (tralokinumab) | Revised |
July 7, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
July 7, 2024 | *CC-0067 | Prostacyclin Infusion and Inhalation Therapy | Revised |
July 7, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
July 7, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
July 7, 2024 | *CC-0057 | Krystexxa (pegloticase) | Revised |
July 7, 2024 | *CC-0068 | Growth Hormones | Revised |
July 7, 2024 | *CC-0047 | Trogarzo | Revised |
July 7, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
July 7, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
July 7, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
July 7, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | 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-059004-24-CPN57972
PUBLICATIONS: July 2024 Provider Newsletter
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Visit https://providernews.anthem.com/kentucky/articles/clinical-criteria-updates-effective-20134
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