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

Notice of material change/amendment to contract

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the August 18, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective January 1, 2024

The following Clinical Criteria are new:

  • CC-0244 Columvi (glofitamab-gxbm)*
  • CC-0246 Rystiggo (rozanolixizumab-noli)*
  • CC-0247 Beyfortus (nirsevimab)*

Revised Clinical Criteria effective January 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-0007 Synagis (palivizumab)*
  • CC-0207 Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)*

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

MEBCBS-CM-038604-23

ATTACHMENTS: CC-0244 (pdf - 0.14mb), CC-0247 (pdf - 0.14mb), CC-0007 (pdf - 0.24mb), CC-0246 (pdf - 0.17mb), CC-0207 (pdf - 0.2mb)

PUBLICATIONS: October 2023 Provider Newsletter