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

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the December 11, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective June 1, 2024

The following Clinical Criteria are new:

  • CC-0255 Loqtorzi (toripalimab-tpzi)*
  • CC-0256 Rivfloza (nedosiran)*

Revised Clinical Criteria effective June 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-0107 Bevacizumab for Non-ophthalmologic Indications*
  • CC-0110 Perjeta (pertuzumab)*
  • CC-0185 Oxlumo (lumasiran)*

* 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-049890-24-SRS49890

ATTACHMENTS: CC-0255 Loqtorzi (toripalimab-tpzi) (pdf - 0mb), CC-0256 Rivfloza (nedosiran) (pdf - 0mb), CC-0002 Colony Stimulating Factor Agents (pdf - 0mb), CC-0107 Bevacizumab for Non-ophthalmologic Indications (pdf - 0mb), CC-0110 Perjeta (pertuzumab) (pdf - 0mb), CC-0185 Oxlumo (lumasiran) (pdf - 0mb)

PUBLICATIONS: March 2024 Provider Newsletter