MedicaidJuly 8, 2024
Clinical Criteria updates — November 2023
Summary
On February 24, 2023, and November 17, 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. 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 | Clinical Criteria number | Clinical Criteria title | New or revised |
August 10, 2024 | *CC-0252 | Adzynma (ADAMTS13, recombinant-krhn) | New |
August 10, 2024 | *CC-0253 | Aphexda (motixafortide) | New |
August 10, 2024 | *CC-0254 | Zilbysq (zilucoplan) | New |
August 10, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
August 10, 2024 | CC-0223 | Imjudo (tremelimumab-actl) | Revised |
August 10, 2024 | *CC-0059 | Selected Injectable NK-1 Antiemetic Agents | Revised |
August 10, 2024 | CC-0074 | Akynzeo (fosnetupitant and palonosetron) for injection | Revised |
August 10, 2024 | *CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
August 10, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
August 10, 2024 | CC-0150 | Kymriah (tisagenlecleucel) | Revised |
August 10, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
August 10, 2024 | CC-0133 | Aliqopa (copanlisib) | Revised |
August 10, 2024 | CC-0205 | Fyarro (sirolimus albumin bound) | Revised |
August 10, 2024 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
August 10, 2024 | *CC-0226 | Elahere (mirvetuximab) | Revised |
August 10, 2024 | CC-0125 | Opdivo (nivolumab) | Revised |
August 10, 2024 | CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | Revised |
August 10, 2024 | *CC-0009 | Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis | Revised |
August 10, 2024 | *CC-0014 | Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis |
Revised |
August 10, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
August 10, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
August 10, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
August 10, 2024 | *CC-0032 | Botulinum Toxin | Revised |
August 10, 2024 | *CC-0068 | Growth Hormone | Revised |
August 10, 2024 | *CC-0173 | Enspryng (satralizumab-mwge) | Revised |
August 10, 2024 | *CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
August 10, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
August 10, 2024 | *CC-0041 | Complement Inhibitors | Revised |
August 10, 2024 | *CC-0071 | Entyvio (vedolizumab) | Revised |
August 10, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
August 10, 2024 | *CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
August 10, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
August 10, 2024 | *CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
August 10, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
August 10, 2024 | *CC-0063 | Ustekinumab Agents | Revised |
August 10, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
August 10, 2024 | CC-0003 | Immunoglobulins | Revised |
August 10, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
August 10, 2024 | CC-0247 | Beyfortus (nirsevimab) | Revised |
August 10, 2024 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
August 10, 2024 | CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
August 10, 2024 | CC-0209 | Leqvio (inclisiran) | Revised |
August 10, 2024 | *CC-0086 | Spravato (esketamine) Nasal Spray | 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-050620-24-CPN49889
PUBLICATIONS: August 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/kentucky/articles/clinical-criteria-updates-november-2023-20477
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