Clinical Criteria Updates - August 2022

Summary: On May 20, 2022, August 19, 2022, and September 9, 2022, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem 

Blue Cross and Blue Shield Healthcare Solutions (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/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	Document number	Clinical Criteria title	New or revised
  August 27, 2023	*ING-CC-0219	Korsuva (difelikefalin acetate)	New
  August 27, 2023	*ING-CC-0220	Xenpozyme (olipudase alfa)	New
  August 27, 2023	*ING-CC-0221	Spevigo (spesolimab-sbzo)	New
  August 27, 2023	ING-CC-0124	Keytruda (pembrolizumab)	Revised
  August 27, 2023	ING-CC-0104	Levoleucovorin Agents	Revised
  August 27, 2023	ING-CC-0100	Istodax (romidepsin)	Revised
  August 27, 2023	ING-CC-0182	Iron Agents	Revised
  August 27, 2023	*ING-CC-0075	Rituximab Agents for Non-Oncologic Indications	Revised
  August 27, 2023	*ING-CC-0167	Rituximab Agents for Oncologic Indications Step Therapy	Revised
  August 27, 2023	*ING-CC-0176	Beleodaq (belinostat)	Revised
  August 27, 2023	ING-CC-0180	Monjuvi (tafasitamab-cxix)	Revised
  August 27, 2023	*ING-CC-0107	Bevacizumab for non-ophthalmologic indications	Revised
  August 27, 2023	*ING-CC-0002	Colony Stimulating Factor Agents	Revised
  August 27, 2023	ING-CC-0187	Breyanzi (lisocabtagene maraleucel)	Revised
  August 27, 2023	ING-CC-0158	Enhertu (fam-trastuzumab deruxtecan-nxki)	Revised
  August 27, 2023	ING-CC-0216	Opdualag (nivolumab and relatlimab-rmbw)	Revised
  August 27, 2023	ING-CC-0196	Zynlonta (loncastuximab tesirine-lpyl)	Revised
  August 27, 2023	ING-CC-0097	Vidaza (azacitidine)	Revised
  August 27, 2023	*ING-CC-0142	Somatuline Depot (lanreotide)	Revised
  August 27, 2023	*ING-CC-0058	Byngezia Pen, Sandostatin, or Sandostatin LAR (Octreotide)/ Octreotide Agents	Revised
  August 27, 2023	*ING-CC-0082	Onpattro (patisiran)	Revised
  August 27, 2023	*ING-CC-0084	Tegsedi (inotersen)	Revised
  August 27, 2023	*ING-CC-0034	Hereditary Angioedema Agents	Revised
  August 27, 2023	ING-CC-0019	Zoledronic Acid Agents	Revised
  August 27, 2023	*ING-CC-0029	Dupixent (dupilumab)	Revised
  August 27, 2023	*ING-CC-0035	Duopa (carbidopa and levodopa enteral suspension)	Revised
  August 27, 2023	ING-CC-0140	Zulresso (brexanolone)	Revised
  August 27, 2023	ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
  August 27, 2023	ING-CC-0188	Imcivree (setmelanotide)	Revised
  August 27, 2023	*ING-CC-0026	Testosterone Injectable	Revised
  August 27, 2023	*ING-CC-0207	Vyvgart (efgartigimod alfa-fcab)	Revised
  August 27, 2023	*ING-CC-0166	Trastuzumab Agents	Revised

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