On December 18, 2020, and December 22, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 would like 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 members of your practice and office staff.

 

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.

 

Effective date

Document number

Clinical Criteria title

New or revised

April 8, 2021

ING-CC-0185*

Oxlumo (lumasiran)

New

April 8, 2021

ING-CC-0184*

Danyelza (naxitamab-gqgk)

New

April 8, 2021

ING-CC-0154

Givlaari (givosiran)

Revised

April 8, 2021

ING-CC-0124

Keytruda (pembrolizumab)

Revised

April 8, 2021

ING-CC-0002

Colony Stimulating Factor Agents

Revised

April 8, 2021

ING-CC-0032*

Botulinum Toxin

Revised

April 8, 2021

ING-CC-0015

Infertility and HCG Agents

Revised

 

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April 2021 Anthem Provider News - Missouri