AMH Health, LLC | Medicare AdvantageAugust 8, 2023
Clinical Criteria updates - May 2023
On December 22, 2022, May 2, 2023, and May 19, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for AMH Health, LLC. These policies were developed, revised, or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: Newly published criteria
- Revised: Addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Please share this notice with other providers in your practice and office staff.
Please note:
- The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by AMH Health only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised |
September 11, 2023 | *CC-0237 | Qalsody (tofersen) | New |
September 11, 2023 | *CC-0238 | Hydroxyprogesterone caproate | New |
September 11, 2023 | *CC-0240 | Zynyz (retifanlimab-dlwr) | New |
September 11, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
September 11, 2023 | CC-0002 | Colony Stimulating Factor Agents | Revised |
September 11, 2023 | CC-0128 | Tecentriq (atezolizumab) | Revised |
September 11, 2023 | CC-0098 | Doxorubicin Liposome (Doxil, Lipodox) | Revised |
September 11, 2023 | CC-0101 | Torisel (temsirolimus) | Revised |
September 11, 2023 | CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
September 11, 2023 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
September 11, 2023 | CC-0092 | Adcetris (brentuximab vedotin) | Revised |
September 11, 2023 | CC-0095 | Velcade (bortezomib) | Revised |
September 11, 2023 | CC-0105 | Vectibix (panitumumab) | Revised |
September 11, 2023 | CC-0178 | Synribo (omacetaxine mepesuccinate) | Revised |
September 11, 2023 | CC-0114 | Jevtana (cabazitaxel) | Revised |
September 11, 2023 | CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
September 11, 2023 | *CC-0032 | Botulinum Toxin | Revised |
September 11, 2023 | CC-0068 | Growth Hormone | Revised |
September 11, 2023 | *CC-0057 | Krystexxa (pegloticase) | Revised |
September 11, 2023 | *CC-0125 | Opdivo (nivolumab) | Revised |
September 11, 2023 | *CC-0225 | Tzield (teplizumab-mzwv) | Revised |
September 11, 2023 | *CC-0124 | Keytruda (pembrolizumab) | Revised |
Plans offered by AMH Health, LLC., a joint venture between MaineHealth and Anthem Partnership Holding Company, LLC. AMH Health is an independent licensee of the Blue Cross Blue Shield Association.
MEAMH-CR-031951-23-CPN30755
PUBLICATIONS: September 2023 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/maine/articles/clinical-criteria-updates-may-2023-3-14962
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