Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialFebruary 1, 2024

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the November 17, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective May 1, 2024

The following Clinical Criteria are new:

  • CC-0253 Aphexda (motixafortide)*
  • CC-0254 Zilbysq (zilucoplan)*

Revised Clinical Criteria effective May 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-0002 Colony Stimulating Factor Agents*
  • CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis*
  • CC-0011 Ocrevus (ocrelizumab)*
  • CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis*
  • CC-0020 Natalizumab Agents (Tysabri, Tyruko)*
  • CC-0032 Botulinum Toxin*
  • CC-0041 Complement Inhibitors*
  • CC-0042 Monoclonal Antibodies to Interleukin-17*
  • CC-0050 Monoclonal Antibodies to Interleukin-23*
  • CC-0062 Tumor Necrosis Factor Antagonists*
  • CC-0063 Ustekinumab Agents (Stelara, Wezlana)*
  • CC-0064 Interleukin-1 Inhibitors*
  • CC-0065 Agents for Hemophilia A and von Willebrand Disease*
  • CC-0066 Monoclonal Antibodies to Interleukin-6*
  • CC-0068 Growth Hormone*
  • CC-0071 Entyvio (vedolizumab)*
  • CC-0078 Orencia (abatacept)*
  • CC-0086 Spravato (esketamine) Nasal Spray*
  • CC-0170 Uplizna (inebilizumab-cdon)*
  • CC-0173 Enspryng (satralizumab-mwge)*
  • CC-0174 Kesimpta (ofatumumab)*
  • CC-0182 Iron Agents*
  • CC-0199 Empaveli (pegcetacoplan)*
  • CC-0226 Elahere (mirvetuximab)*

* 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-048682-23

ATTACHMENTS: CC-0078 Orencia (abatacept) (pdf - 0.28mb), CC-0065 Agents for Hemophilia A and von Willebrand Disease (pdf - 0.28mb), CC-0064 Interleukin-1 Inhibitors (pdf - 0.28mb), CC-0182 Iron Agents (pdf - 0.26mb), CC-0173 Enspryng (satralizumab-mwge) (pdf - 0.16mb), CC-0174 Kesimpta (ofatumumab) (pdf - 0.18mb), CC-0062 Tumor Necrosis Factor Antagonists (pdf - 0.46mb), CC-0071 Entyvio (vedolizumab) (pdf - 0.22mb), CC-0253 Aphexda (motixafortide) (pdf - 0.13mb), CC-0199 Empaveli (pegcetacoplan) (pdf - 0.2mb), CC-0170 Uplizna (inebilizumab-cdon) (pdf - 0.15mb), CC-0063 Ustekinumab Agents (Stelara, Wezlana) (pdf - 0.21mb), CC-0226 Elahere (mirvetuximab) (pdf - 0.2mb), CC-0086 Spravato (esketamine) Nasal Spray (pdf - 0.19mb), CC-0066 Monoclonal Antibodies to Interleukin-6 (pdf - 0.22mb), CC-0011 Ocrevus (ocrelizumab) (pdf - 0.24mb), CC-0068 Growth Hormone (pdf - 0.23mb), CC-0002 Colony Stimulating Factor Agents (pdf - 0.48mb), CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis (pdf - 0.15mb), CC-0050 Monoclonal Antibodies to Interleukin-23 (pdf - 0.23mb), CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis (pdf - 0.19mb), CC-0042 Monoclonal Antibodies to Interleukin-17 (pdf - 0.26mb), CC-0020 Natalizumab Agents (Tysabri, Tyruko) (pdf - 0.22mb), CC-0254 Zilbysq (zilucoplan) (pdf - 0.16mb), CC-0032 Botulinum Toxin (pdf - 0.26mb), CC-0041 Complement Inhibitors (pdf - 0.22mb)

PUBLICATIONS: February 2024 Provider Newsletter