Medicare AdvantageMay 22, 2025
New specialty pharmacy medical step therapy requirements
Starting July 1, 2025, the following Part B medications from the current Clinical Criteria Guidelines will be included in our medical step therapy precertification review process.
Step therapy will apply to members upon precertification initiation in addition to the current medical necessity review.
Step therapy will not apply to members actively receiving the medications listed below.
Clinical Criteria Guidelines are publicly available at https://anthem.com/provider/medicare‑advantage. Visit the Clinical Criteria page to search for specific criteria.
Clinical UM Guidelines | Status | Drug(s) |
CC-0072 | Preferred | Pavblu (aflibercept-ayyh) |
CC-0072 | Non-preferred | Ahzantive (aflibercept-mrbb) |
CC-0072 | Non-preferred | Enzeevu (aflibercept-abzv) |
CC-0072 | Non-preferred | Opuviz (afibercept-yszy) |
CC-0072 | Non-preferred | Yesafili (aflibercept-jbvf) |
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-081303-25-CPN81191
PUBLICATIONS: June 2025 Provider Newsletter
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