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

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the May 17, 2024, Clinical Criteria meeting. Visit Clinical Criteria In Pharmacy to access the Clinical Criteria information.

New Clinical Criteria effective November 1, 2024

The following Clinical Criteria are new:

  • CC-0262 Tevimbra (tislelizumab-jsgr)*

Revised Clinical Criteria effective November 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-0063 Ustekinumab Agents (Stelara, Selarsdi, Wezlana)*
  • CC-0066 Monoclonal Antibodies to Interleukin-6*
  • CC-0092 Adcetris (brentuximab vedotin)*
  • CC-0098 Doxorubicin Liposome (Doxil)*
  • CC-0105 Vectibix (panitumumab)*
  • CC-0107 Bevacizumab for Non-ophthalmologic Indications*
  • CC-0111 Nplate (romiplostim)*
  • CC-0124 Keytruda (pembrolizumab)*
  • CC-0130 Imfinzi (durvalumab)*
  • CC-0162 Tepezza (teprotumumab-trbw)*
  • CC-0188 Imcivree (setmelanotide)*
  • CC-0199 Empaveli (pegcetacoplan)*
  • CC-0221 Spevigo (spesolimab-sbzo)*

* 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-062736-24-SRS62682

ATTACHMENTS: CC-0002_Original (pdf - 0.49mb), CC-0002_Redline (pdf - 1.06mb), CC-0063_Original (pdf - 0.22mb), CC-0063_Redline (pdf - 0.69mb), CC-0066_Original (pdf - 0.29mb), CC-0066_Redline (pdf - 0.64mb), CC-0092_Original (pdf - 0.23mb), CC-0092_Redline (pdf - 0.67mb), CC-0098_Original (pdf - 0.22mb), CC-0098_Redline (pdf - 0.64mb), CC-0105_Original (pdf - 0.17mb), CC-0105_Redline (pdf - 0.65mb), CC-0107_Original (pdf - 0.33mb), CC-0107_Redline (pdf - 0.85mb), CC-0111_Original (pdf - 0.18mb), CC-0111_Redline (pdf - 0.65mb), CC-0124_Original (pdf - 0.43mb), CC-0124_Redline (pdf - 0.9mb), CC-0130_Original (pdf - 0.2mb), CC-0130_Redline (pdf - 0.73mb), CC-0162_Original (pdf - 0.23mb), CC-0162_Redline (pdf - 0.66mb), CC-0188_Original (pdf - 0.23mb), CC-0188_Redline (pdf - 0.7mb), CC-0199_Original (pdf - 0.2mb), CC-0199_Redline (pdf - 0.49mb), CC-0221_Original (pdf - 0.21mb), CC-0221_Redline (pdf - 0.67mb), CC-0262_Original (pdf - 0.18mb)

PUBLICATIONS: August 2024 Provider Newsletter