Medicare AdvantageJuly 28, 2025
Clinical Criteria updates
Effective September 4, 2025
Summary: The pharmacy and therapeutics (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 our Clinical Criteria page to search for specific policies. For questions or additional information, please reach out via 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
Please share this notice with other members of 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 plan. This does not apply to pharmacy services.
- This notice is meant to provide information on 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 | Status |
September 4, 2025 | CC‑0283 | Imaavy (nipocalimab) | New |
September 4, 2025 | CC‑0111 | Nplate (romiplostim) | Revised |
September 4, 2025 | CC‑0002 | Colony Stimulating Factor Agents | Revised |
September 4, 2025 | CC‑0165 | Trodelvy (sacituzumab govitecan) | Revised |
September 4, 2025 | CC‑0128 | Atezolizumab (Tecentriq, Tecentriq Hybreza) | Revised |
September 4, 2025 | CC‑0098 | Doxorubicin Liposome (Doxil) | Revised |
September 4, 2025 | CC‑0107 | Bevacizumab for Non‑Ophthalmologic Indications | Revised |
September 4, 2025 | CC‑0143 | Polivy (polatuzumab vedotin‑piiq) | Revised |
September 4, 2025 | CC‑0092 | Adcetris (brentuximab vedotin) | Revised |
September 4, 2025 | CC‑0106 | Erbitux (cetuximab) | Revised |
September 4, 2025 | CC‑0105 | Vectibix (panitumumab) | Revised |
September 4, 2025 | CC‑0145 | Libtayo (cemiplimab‑rwlc) | Revised |
September 4, 2025 | CC‑0102 | GNRH Analogs for Oncologic Indications | Revised |
September 4, 2025 | CC‑0087 | Gamifant (emapalumab) | Revised |
September 4, 2025 | CC‑0201 | Rybrevant (amivantamab‑ymjw) | Revised |
September 4, 2025 | CC‑0169 | Phesgo (pertuzumab/trastuzumab/hyaluronidase‑zzxf) | Revised |
September 4, 2025 | CC‑0130 | Imfinzi (durvalumab) | Revised |
September 4, 2025 | CC‑0240 | Zynyz (retifanlimab‑dlwr) | Revised |
September 4, 2025 | CC‑0125 | Opdivo (nivolumab) | Revised |
September 4, 2025 | CC‑0119 | Yervoy (ipilimumab) | Revised |
September 4, 2025 | CC‑0281 | Opdivo Qvantig (nivolumab hyaluronidase‑nvhy) | Revised |
September 4, 2025 | CC‑0232 | Lunsumio (mosunetuzumab‑axgb) | Revised |
September 4, 2025 | CC‑0262 | Tevimbra (tislelizumab‑jsgr) | Revised |
September 4, 2025 | CC‑0274 | Bizengri (zenocutuzumab‑zbco) | Revised |
September 4, 2025 | CC‑0094 | Pemetrexed | Revised |
September 4, 2025 | CC‑0027 | Denosumab | Revised |
September 4, 2025 | CC‑0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
September 4, 2025 | CC‑0124 | Keytruda (pembrolizumab) | Revised |
September 4, 2025 | CC‑0188 | Imcivree (setmelanotide) | Revised |
September 4, 2025 | CC‑0225 | Tzield (teplizumab‑mzwv) | Revised |
September 4, 2025 | CC‑0064 | Interleukin‑1 Inhibitors | Revised |
September 4, 2025 | CC‑0062 | Tumor Necrosis Factor Antagonists | Revised |
September 4, 2025 | CC‑0078 | Orencia (abatacept) | Revised |
September 4, 2025 | CC‑0066 | Monoclonal Antibodies to Interleukin‑6 | Revised |
September 4, 2025 | CC‑0063 | Ustekinumab Agents | Revised |
September 4, 2025 | CC‑0003 | Immunoglobulins | Revised |
September 4, 2025 | CC‑0050 | Monoclonal Antibodies to Interleukin‑23 | Revised |
September 4, 2025 | CC‑0029 | Dupixent (dupilumab) | Revised |
September 4, 2025 | CC‑0217 | Amvuttra (vutrisiran) | Revised |
September 4, 2025 | CC‑0033 | Omalizumab Agents (Xolair, Omlyclo) | Revised |
September 4, 2025 | CC‑0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CR-087694-25-CPN86951
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