Medicare AdvantageMay 7, 2024
Clinical Criteria updates
Effective June 10, 2024
Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. 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 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 Anthem 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 |
June 10, 2024 | *CC-0258 | iDoseTR (travoprost Implant) | New |
June 10, 2024 | *CC-0259 | Amtagvi (lifleucel) | New |
June 10, 2024 | *CC-0260 | Nexobrid (anacaulase-bcdb) | New |
June 10, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
June 10, 2024 | *CC-0041 | Complement Inhibitors | Revised |
June 10, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
June 10, 2024 | CC-0116 | Bendamustine agents | Revised |
June 10, 2024 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
June 10, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
June 10, 2024 | CC-0157 | Padcev (enfortumab vedotin) | Revised |
June 10, 2024 | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | Revised |
June 10, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised |
June 10, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised |
June 10, 2024 | *CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
June 10, 2024 | *CC-0093 | Docetaxel (Taxotere) | Revised |
June 10, 2024 | *CC-0094 | Pemetrexed (Alimta, Pemfexy, Pemrydi) | Revised |
June 10, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
June 10, 2024 | *CC-0088 | Elzonris (tagraxofusp-erzs) | Revised |
June 10, 2024 | *CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
June 10, 2024 | *CC-0112 | Xofigo (Radium Ra 223 Dichloride) | Revised |
June 10, 2024 | *CC-0123 | Cyramza (ramucirumab) | Revised |
June 10, 2024 | *CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
June 10, 2024 | CC-0121 | Gazyva (obinutuzumab) | Revised |
June 10, 2024 | CC-0122 | Arzerra (ofatumumab) | Revised |
June 10, 2024 | CC-0232 | Lunsumio (mosunetuzumab-axgb) | Revised |
June 10, 2024 | CC-0109 | Zaltrap (ziv-aflibercept) | Revised |
June 10, 2024 | CC-0135 | Melanoma Vaccines | Revised |
June 10, 2024 | *CC-0096 | Asparagine Specific Enzymes | Revised |
June 10, 2024 | CC-0120 | Kyprolis (carfilzomib) | Revised |
June 10, 2024 | *CC-0117 | Empliciti (elotuzumab) | Revised |
June 10, 2024 | *CC-0126 | Blincyto (blinatumomab) | Revised |
June 10, 2024 | CC-0113 | Sylvant (siltuximab) | Revised |
June 10, 2024 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
June 10, 2024 | CC-0097 | Vidaza (azacitidine) | Revised |
June 10, 2024 | CC-0129 | Bavencio (avelumab) | Revised |
June 10, 2024 | *CC-0090 | Ixempra (ixabepilone) | Revised |
June 10, 2024 | CC-0110 | Perjeta (pertuzumab) | Revised |
June 10, 2024 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
June 10, 2024 | *CC-0108 | Halaven (eribulin) | Revised |
June 10, 2024 | CC-0089 | Mozobil (plerixafor) | Revised |
June 10, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
June 10, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
June 10, 2024 | *CC-0212 | Tezspire (tezepelumab-ekko) | Revised |
June 10, 2024 | *CC-0033 | Xolair (omalizumab) | Revised |
June 10, 2024 | *CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
June 10, 2024 | *CC-0029 | Dupixent (dupilumab) | Revised |
June 10, 2024 | *CC-0208 | Adbry (tralokinumab) | Revised |
June 10, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
June 10, 2024 | *CC-0067 | Prostacyclin Infusion and Inhalation Therapy | Revised |
June 10, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
June 10, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
June 10, 2024 | *CC-0057 | Krystexxa (pegloticase) | Revised |
June 10, 2024 | *CC-0068 | Growth Hormones | Revised |
June 10, 2024 | *CC-0047 | Trogarzo | Revised |
June 10, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
June 10, 2024 | *CC-0107 | Bevacizumab for Non-ophthalmologic Indications | Revised |
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CR-058781-24-CPN57659
PUBLICATIONS: June 2024 Provider Newsletter
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