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

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the September 27, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective March 1, 2024

The following Clinical Criteria are new:

  • CC-0250 Veopoz (pozelimab-bbfg)*
  • CC-0251 Ycanth (cantharidin)*

Revised Clinical Criteria effective March 1, 2024

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-0018 Pompe Disease [Lumizyme (alglucosidase alfa), Nexviazyme (avalglucosidase alfa-ngpt), Pombiliti (cipaglucosidase alfa-atga)]*
  • CC-0020 Natalizumab Agents (Tysabri, Tyruko)*
  • CC-0021 Fabrazyme (agalsidase beta)*
  • CC-0046 Zinplava (bezlotoxumab)*
  • CC-0068 Growth Hormones*
  • CC-0233 Rebyota (fecal microbiota, live — jslm)*

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

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MEBCBS-CM-044211-23-SRS44075

ATTACHMENTS: CC-0021_Pub 10-23-2023 (pdf - 0.19mb), CC-0068_Pub 10-03-2023 (pdf - 0.26mb), CC-0046_Pub 10-23-2023 (pdf - 0.26mb), CC-0250_Pub 10-03-2023 (pdf - 0.17mb), CC-0233_Pub 10-23-2023 (pdf - 0.16mb), CC-0251_Pub 10-03-2023 (pdf - 0.14mb), CC-0018_Pub 10-10-2023 (pdf - 0.19mb), CC-0020_Pub 10-03-2023 (pdf - 0.21mb)

PUBLICATIONS: December 2023 Provider Newsletter