Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialJune 1, 2025

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

Visit Clinical Criteria In Pharmacy to access the Clinical Criteria information.

New Clinical Criteria effective September 1, 2025

  • CC‑0278 Unloxcyt (cosibelimab‑ipdl)*
  • CC‑0279 Datroway (datopotamab deruxtecan‑dlnk)*
  • CC‑0281 Opdivo Qvantig (nivolumab hyaluronidase‑nvhy)*
  • CC‑0282 Onapgo (apomorphine subcutaneous solution)*

Revised Clinical Criteria effective September 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‑0008 Subcutaneous Hormonal Implants*
  • CC‑0015 Infertility and HCG Agents*
  • CC‑0027 Denosumab*
  • CC‑0029 Dupixent (dupilumab)*
  • CC‑0037 Kanuma (sebelipase alfa)*
  • CC‑0050 Monoclonal Antibodies to Interleukin‑23*
  • CC‑0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non‑Oncologic Indications*
  • CC‑0063 Ustekinumab Agents (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Wezlana)*
  • CC‑0066 Monoclonal Antibodies to Interleukin‑6*
  • CC‑0119 Yervoy (ipilimumab)*
  • CC‑0121 Gazyva (obinutuzumab)*
  • CC‑0122 Arzerra (ofatumumab)*
  • CC‑0125 Opdivo (nivolumab)*
  • CC‑0149 Select Clotting Agents for Bleeding Disorders*
  • CC‑0158 Enhertu (fam‑trastuzumab deruxtecan‑nxki)*
  • CC‑0159 Scenesse (afamelanotide)*
  • CC‑0215 Ketamine injection (Ketalar)*
  • CC‑0261 Winrevair (sotatercept‑csrk)*
  • CC‑0267 Ebglyss (lebrikizumab‑lbkz)*
  • CC‑0269 Nemluvio (nemolizumab‑ilto)*

* 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-083547-25

ATTACHMENTS: CC-0008_Subcutaneous Hormonal Implants_Pub 4.1.25 (final) (pdf - 0.22mb), CC-0008_Subcutaneous Hormonal Implants_Pub 4.1.25 (redline) (pdf - 0.16mb), CC-0015_Infertility and HCG Agents_Pub 4.1.25 (final) (pdf - 0.24mb), CC-0015_Infertility and HCG Agents_Pub 4.1.25 (redline) (pdf - 0.19mb), CC-0027_Denosumab Agents_Pub 4.10.25 (redline) (pdf - 0.17mb), CC-0027_Denosumab-Agents_Pub 4.10.25 (final) (pdf - 0.22mb), CC-0029_Dupixent_Pub 03.18.25 (final) (pdf - 0.28mb), CC-0029_Dupixent_Pub 3.18.25 (redline) (pdf - 0.2mb), CC-0037_Kanuma_Pub 4.24.25 (final) (pdf - 0.14mb), CC-0037_Kanuma_Pub 4.24.25 (redline) (pdf - 0.12mb), CC-0050_Monoclonal Antibodies to Interleukin-23_Pub 3.18.25 (final) (pdf - 0.32mb), CC-0050_Monoclonal Antibodies to Interleukin-23_Pub 3.18.25 (redline) (pdf - 0.24mb), CC-0061_GnRH Analogs for the Tx Non-Onc Indications_Pub 4.1.25 (final) (pdf - 0.2mb), CC-0061_GnRH Analogs for the Tx Non-Onc Indications_Pub 4.1.25 (redline) (pdf - 0.17mb), CC-0063_Ustekinumab Agents_Pub 3.18.25 (redline) (pdf - 0.23mb), CC-0063_ustekinumab_Pub 03.18.25 (final) (pdf - 0.24mb), CC-0066_Monoclonal Antibodies to Interleukin-6_Pub 4.10.25 (redline) (pdf - 0.21mb), CC-0066_Monoclonal-Antibodies-to-Interleukin-6_Pub 4.10.25 (final) (pdf - 0.22mb), CC-0119_Yervoy_Pub 4.1.25 (final) (pdf - 0.3mb), CC-0119_Yervoy_Pub 4.1.25 (redline) (pdf - 0.23mb), CC-0121_Gazyva_Pub 4.1.25 (final) (pdf - 0.27mb), CC-0121_Gazyva_Pub 4.1.25 (redline) (pdf - 0.16mb), CC-0122_Arzerra_Pub 4.1.25 (final) (pdf - 0.16mb), CC-0122_Arzerra_Pub 4.1.25 (redline) (pdf - 0.13mb), CC-0125_Opdivo_Pub 4.1.25 (final) (pdf - 0.36mb), CC-0125_Opdivo_Pub 4.1.25 (redline) (pdf - 0.37mb), CC-0149_Select Clotting Agents for Bleeding Disorders_Pub 3.18.25 (redline) (pdf - 0.23mb), CC-0149_Select Clotting Agents for Bleeding Disorders_Pub 5.1.25 (final) (pdf - 0.24mb), CC-0149_Select Clotting Agents for Bleeding Disorders_Pub 5.1.25 (redline) (pdf - 0.23mb), CC-0149_Select-Clotting-Agents-Bleeding-Disorders_Pub 3.18.25 (final) (pdf - 0.23mb), CC-0158_Enhertu_Pub 4.1.25 (final) (pdf - 0.24mb), CC-0158_Enhertu_Pub 4.1.25 (redline) (pdf - 0.2mb), CC-0159_Scenesse_Pub 4.24.25 (final) (pdf - 0.17mb), CC-0159_Scenesse_Pub 4.24.25 (redline) (pdf - 0.13mb), CC-0215_Ketamine Injection_Pub 4.24.25 (final) (pdf - 0.21mb), CC-0215_Ketamine Injection_Pub 4.24.25 (redline) (pdf - 0.17mb), CC-0261_Winrevair_Pub 4.1.25 (final) (pdf - 0.19mb), CC-0261_Winrevair_Pub 4.1.25 (redline) (pdf - 0.12mb), CC-0267_Ebglyss_Pub 3.18.25 (final) (pdf - 0.14mb), CC-0267_Ebglyss_Pub 3.18.25 (redline) (pdf - 0.11mb), CC-0269_Nemluvio_Pub 3.18.25 (final) (pdf - 0.14mb), CC-0269_Nemluvio_Pub 3.18.25 (redline) (pdf - 0.12mb), CC-0278_Unloxcyt_Pub 3.18.25 (final) (pdf - 0.14mb), CC-0279_Datroway_Pub 03-18-25 (final) (pdf - 0.18mb), CC-0281_Opdivo-Qvantig_Pub 3.18.25 (final) (pdf - 0.27mb), CC-0282_Onapgo_Pub 4.10.25 (final) (pdf - 0.14mb)

PUBLICATIONS: June 2025 Provider Newsletter