Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialMay 31, 2023

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the March 23, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective September 1, 2023

The following Clinical Criteria are new:

  • CC-0235 Revcovi (elapegademase-lvlr)*
  • CC-0236 Signifor LAR (pasireotide)*

Revised Clinical Criteria effective September 1, 2023

The following Clinical Criteria were revisedand might result in services that were previously covered but may now be found to be not medically necessary:

  • CC-0034 Hereditary Angioedema Agents*
  • CC-0065 Hemophilia A and von Willebrand Disease*
  • CC-0119 Yervoy (ipilimumab)*
  • CC-0197 Jemperli (dostarlimab-gxly)*

* The applicable policy is attached to this article in PDF format.

MEBCBS-CM-024682-23-SRS24682

ATTACHMENTS: CC-0235_Pub 04-04-2023.pdf (pdf - 0.15mb), CC-0197_Pub 04-04-2023.pdf (pdf - 0.17mb), CC-0236_Pub 04-04-2023.pdf (pdf - 0.13mb), CC-0034_Pub 04-24-2023.pdf (pdf - 0.34mb), CC-0065_Pub 04-24-2023.pdf (pdf - 0.28mb), CC-0119_Pub 04-04-2023.pdf (pdf - 0.27mb)

PUBLICATIONS: June 2023 Provider Newsletter