MedicaidJune 22, 2023
Clinical Criteria updates for February 2023
Summary: On May 20, 2022, August 19, 2022, September 12, 2022, September 15, 2022, November 18, 2022, December 12, 2022, and February 24, 2023, 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 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 | Document number | Clinical Criteria title | New or revised |
July 28, 2023 | *CC-0232 | Lunsumio (mosunetuzumab-axgb) | New |
July 28, 2023 | *CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | New |
July 28, 2023 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | New |
July 28, 2023 | *CC-0234 | Syfovre (pegcetacoplan) | New |
July 28, 2023 | *CC-0231 | Lamzede (velmanase alfa-tycv) | New |
July 28, 2023 | CC-0007 | Synagis (palivizumab) | Revised |
July 28, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
July 28, 2023 | CC-0210 | Enjaymo (sutimlimab-jome) | Revised |
July 28, 2023 | *CC-0128 | Tecentriq (atezolizumab) | Revised |
July 28, 2023 | *CC-0116 | Bendamustine agents | Revised |
July 28, 2023 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
July 28, 2023 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
July 28, 2023 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
July 28, 2023 | *CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
July 28, 2023 | CC-0125 | Opdivo (nivolumab) | Revised |
July 28, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised |
July 28, 2023 | CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
July 28, 2023 | *CC-0093 | Docetaxel (Taxotere) | Revised |
July 28, 2023 | CC-0094 | Pemetrexed Agents (Alimta, Pemfexy) | Revised |
July 28, 2023 | CC-0130 | Imfinzi (durvalumab) | Revised |
July 28, 2023 | CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
July 28, 2023 | CC-0123 | Cyramza (ramucirumab) | Revised |
July 28, 2023 | CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
July 28, 2023 | CC-0121 | Gazyva (obinutuzumab) | Revised |
July 28, 2023 | *CC-0096 | Asparagine Specific Enzymes | Revised |
July 28, 2023 | *CC-0120 | Kyprolis (carfilzomib) | Revised |
July 28, 2023 | CC-0117 | Empliciti (elotuzumab) | Revised |
July 28, 2023 | CC-0126 | Blincyto (blinatumomab) | Revised |
July 28, 2023 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
July 28, 2023 | CC-0097 | Vidaza (azacitidine) | Revised |
July 28, 2023 | CC-0129 | Bavencio (avelumab) | Revised |
July 28, 2023 | CC-0090 | Ixempra (ixabepilone) | Revised |
July 28, 2023 | *CC-0110 | Perjeta (pertuzumab) | Revised |
July 28, 2023 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
July 28, 2023 | CC-0124 | Keytruda (pembrolizumab) | Revised |
July 28, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
July 28, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
July 28, 2023 | *CC-0160 | Vyepti (eptinezumab) | Revised |
July 28, 2023 | *CC-0034 | Hereditary Angioedema Agents | Revised |
July 28, 2023 | *CC-0020 | Tysabri (natalizumab) | Revised |
July 28, 2023 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
July 28, 2023 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
July 28, 2023 | *CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
July 28, 2023 | *CC-0001 | Erythropoiesis Stimulating Agents | Revised |
July 28, 2023 | *CC-0166 | Trastuzumab Agents | Revised |
July 28, 2023 | *CC-0075 | Rituximab agents for Non-Oncologic Indications | Revised |
July 28, 2023 | *CC-0167 | Rituximab Agents for Oncologic Indications | Revised |
July 28, 2023 | *CC-0209 | Leqvio (inclisiran) | Revised |
July 28, 2023 | *CC-0182 | Iron Agents | Revised |
July 28, 2023 | *CC-0107 | Bevacizumab for Non-ophthalmologic Indications | Revised |
July 28, 2023 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
KYBCBS-CD-024308-23-CPN24009
PUBLICATIONS: July 2023 Provider Newsletter
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