Policy UpdatesMedicaidOctober 3, 2024

Clinical Criteria updates

Effective November 4, 2024

Summary: On June 10, 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 need 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

November 4, 2024

*CC-0263

Imdelltra (tarlatamab-dlle)

New

November 4, 2024

*CC-0264

Anktiva (nogapendekin alfa inbekicept-pmln)

New

November 4, 2024

*CC-0265

Kisunla (donanemab)

New

November 4, 2024

*CC-0166

Trastuzumab Agents

Revised

November 4, 2024

CC-0187

Breyanzi (lisocabtagene maraleucel)

Revised

November 4, 2024

CC-0118

Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)

Revised

November 4, 2024

CC-0094

Pemetrexed (Alimta, Pemfexy, Pemrydi)

Revised

November 4, 2024

CC-0032

Botulinum Toxin

Revised

November 4, 2024

*CC-0041

Complement C5 Inhibitors

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-066660-24-CPN65125

PUBLICATIONS: November 2024 Provider Newsletter