Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialAugust 1, 2023

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the May 19, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective November 1, 2023

The following Clinical Criteria is new:

  • CC-0240 Zynyz (retifanlimab-dlwr)*

Revised Clinical Criteria effective November 1, 2023

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

  • CC-0032 Botulinum Toxin*
  • CC-0057 Krystexxa (pegloticase)*
  • CC-0068 Growth Hormone*
  • CC-0124 Keytruda (pembrolizumab)*
  • CC-0125 Opdivo (nivolumab)*
  • CC-0225 Tzield (teplizumab-mzwv)*
* The applicable policy is attached to this article in PDF format.

MEBCBS-CM-028995-23

ATTACHMENTS: CC-0032_Pub 06-20-2023 (pdf - 0.26mb), CC-0057_Pub 06-20-2023 (pdf - 0.21mb), CC-0068_Pub 06-20-2023 (pdf - 0.26mb), CC-0124_Pub 06-02-2023 (pdf - 0.4mb), CC-0125_Pub 06-02-2023 (pdf - 0.34mb), CC-0225_Pub 06-20-2023 (pdf - 0.2mb), CC-0240_Pub 06-20-2023 (pdf - 0.13mb)

PUBLICATIONS: August 2023 Provider Newsletter