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

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the August 16, 2024, Clinical Criteria meeting. Visit Clinical Criteria In Pharmacy to access the Clinical Criteria information.

New Clinical Criteria effective January 1, 2025

The following Clinical Criteria are new:

  • CC-0266 Rytelo (imetelstat)*

Revised Clinical Criteria effective January 1, 2025

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-0003 Immunoglobulins*
  • CC-0007 Synagis (palivizumab)*
  • CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors*
  • CC-0027 Denosumab Agents*
  • CC-0028 Benlysta (belimumab)*
  • CC-0029 Dupixent (dupilumab)*
  • CC-0048 Spinraza (nusinersen)*
  • CC-0058 Octreotide Agents*
  • CC-0082 Onpattro (patisiran)*
  • CC-0193 Evkeeza (evinacumab)*
  • CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended -release) Injection*
  • CC-0207 Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)*
  • CC-0217 Amvuttra (vulrisiran)*
  • CC-0246 Rystiggo (rozanolixizumab-noli)*

* 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-067759-24

ATTACHMENTS: CC-0002 Colony-Stimulating-Factor-Agents (final) (pdf - 0.5mb), CC-0002 Colony Stimulating Factor Agents (redline) (pdf - 0.46mb), CC-0003 Immunoglobulins (final) (pdf - 0.45mb), CC-0003 Immunoglobulins (redline) (pdf - 0.45mb), CC-0007 Synagis (final) (pdf - 0.23mb), CC-0007 Synagis (redline) (pdf - 0.2mb), CC-0010 PCSK9 Inhibitor (final) (pdf - 0.21mb), CC-0010 PCSK9 Inhibitor (redline) (pdf - 0.22mb), CC-0027 Denosumab-Agents (final) (pdf - 0.21mb), CC-0027 Denosumab Agents (redline) (pdf - 0.2mb), CC-0028 Benlysta (final) (pdf - 0.18mb), CC-0028 Benlysta (redline) (pdf - 0.18mb), CC-0029 Dupixent (final) (pdf - 0.27mb), CC-0029 Dupixent (redline) (pdf - 0.22mb), CC-0048 Spinraza (final) (pdf - 0.23mb), CC-0048 Spinraza (redline) (pdf - 0.19mb), CC-0058 Octreotide Agents (final) (pdf - 0.21mb), CC-0058 Octreotide Agents (redline) (pdf - 0.2mb), CC-0082 Onpattro (final) (pdf - 0.18mb), CC-0082 Onpattro (redline) (pdf - 0.13mb), CC-0193 Evkeeza (final) (pdf - 0.18mb), CC-0193 Evkeeza (redline) (pdf - 0.18mb), CC-0194 Cabenuva (final) (pdf - 0.14mb), CC-0194 Cabenuva (redline) (pdf - 0.15mb), CC-0217 Amvuttra (final) (pdf - 0.2mb), CC-0217 Amvuttra (redline) (pdf - 0.15mb), CC-0246 Rystiggo (final) (pdf - 0.17mb), CC-0246 Rystiggo (redline) (pdf - 0.15mb), CC-0266 Rytelo (final) (pdf - 0.13mb)

PUBLICATIONS: October 2024 Provider Newsletter