Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialMay 1, 2023

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the February 24, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective August 1, 2023

The following Clinical Criteria are new:

  • CC-0230 Adstiladrin (nadofaragene firadenovec-vncg)*
  • CC-0233 Rebyota (fecal microbiota, live – jslm)*

Revised Clinical Criteria effective August 1, 2023

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-0062 Tumor Necrosis Factor Antagonists*
  • CC-0086 Spravato (esketamine) Nasal Spray*
  • CC-0096 Asparagine Specific Enzymes*
  • CC-0110 Perjeta (pertuzumab)*
  • CC-0115 Kadcyla (ado-trastuzumab)*
  • CC-0116 Bendamustine agents*
  • CC-0119 Yervoy (ipilimumab)*
  • CC-0120 Kyprolis (carfilzomib)*
  • CC-0128 Tecentriq (atezolizumab)*
  • CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)*

*The applicable policy is attached to this article in PDF format.

MEBCBS-CM-022602-23

ATTACHMENTS: CC-0062_Pub 03-27-2023.pdf (pdf - 0.43mb), CC-0086_Pub 03-27-2023.pdf (pdf - 0.18mb), CC-0096_Pub 03-27-2023.pdf (pdf - 0.22mb), CC-0110_Pub 03-27-2023.pdf (pdf - 0.23mb), CC-0115_Pub 03-27-2023.pdf (pdf - 0.22mb), CC-0116_Pub 03-27-2023.pdf (pdf - 0.18mb), CC-0119_Pub 03-27-2023.pdf (pdf - 0.36mb), CC-0120_Pub 03-27-2023.pdf (pdf - 0.23mb), CC-0128_Pub 03-27-2023.pdf (pdf - 0.25mb), CC-0158_Pub 03-27-2023.pdf (pdf - 0.29mb), CC-0230_Pub 03-08-2023.pdf (pdf - 0.2mb), CC-0233_Pub 03-08-2023.pdf (pdf - 0.16mb)

PUBLICATIONS: May 2023 Provider News