Policy UpdatesMedicaidSeptember 20, 2024

Clinical Criteria updates

Effective October 23, 2024

Summary: On November 17, 2023, and March 21, 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. For questions or additional information, use this email.

Please see the explanation or 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

October 23, 2024

*CC-0261

Winrevair (sotatercept-csrk)

New

October 23, 2024

*CC-0125

Opdivo (nivolumab)

Revised

October 23, 2024

*CC-0003

Immunoglobulins

Revised

October 23, 2024

CC-0033

Xolair (omalizumab)

Revised

October 23, 2024

*CC-0062

Tumor Necrosis Factor Antagonists

Revised

October 23, 2024

CC-0121

Gazyva (obinutuzumab)

Revised

October 23, 2024

CC-0201

Rybrevant (amivantamab-ymjw)

Revised

October 23, 2024

*CC-0251

Ycanth (cantharidin)

Revised

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CD-060436-24-CPN59849

PUBLICATIONS: October 2024 Provider Newsletter