Policy UpdatesMedicare AdvantageJune 9, 2023

Clinical Criteria updates February 2023

Clinical Criteria updates in Nevada

Summary

On February 24, 2023, 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 (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 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

July 14, 2023

*CC-0232

Lunsumio (mosunetuzumab-axgb)

New

 

July 14, 2023

*CC-0230

Adstiladrin (nadofaragene firadenovec-vncg)

New

July 14, 2023

*CC-0233

Rebyota (fecal microbiota, live – jslm)

New

July 14, 2023

*CC-0234

Syfovre (pegcetacoplan) 

New

July 14, 2023

*CC-0231

Lamzede (velmanase alfa-tycv)

New

July 14, 2023

CC-0007

Synagis (palivizumab)

Revised

 

July 14, 2023

CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

July 14, 2023

CC-0210

Enjaymo (sutimlimab-jome)

Revised

July 14, 2023

*CC-0128

Tecentriq (atezolizumab)

Revised

July 14, 2023

*CC-0116

Bendamustine agents

Revised

July 14, 2023

CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

July 14, 2023

CC-0161

Sarclisa (isatuximab-irfc)

Revised

July 14, 2023

*CC-0086

Spravato (esketamine) Nasal Spray

Revised

July 14, 2023

*CC-0158

Enhertu (fam-trastuzumab deruxtecan-nxki)

Revised

July 14, 2023

CC-0125

Opdivo (nivolumab)

Revised

July 14, 2023

*CC-0119

Yervoy (ipilimumab)

Revised

July 14, 2023

CC-0099

Abraxane (paclitaxel, protein bound)

Revised

July 14, 2023

*CC-0093

Docetaxel (Taxotere)

Revised

July 14, 2023

CC-0094

Pemetrexed Agents (Alimta, Pemfexy)

Revised

July 14, 2023

CC-0130

Imfinzi (durvalumab)

Revised

July 14, 2023

CC-0118

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

Revised

July 14, 2023

CC-0123

Cyramza (ramucirumab)

Revised

July 14, 2023

CC-0131

Besponsa (inotuzumab ozogamicin)

Revised

July 14, 2023

CC-0121

Gazyva (obinutuzumab)

Revised

July 14, 2023

*CC-0096

Asparagine Specific Enzymes

Revised

July 14, 2023

*CC-0120

Kyprolis (carfilzomib)

Revised

July 14, 2023

CC-0117

Empliciti (elotuzumab)

Revised

July 14, 2023

CC-0126

Blincyto (blinatumomab)

Revised

July 14, 2023

CC-0132

Mylotarg (gemtuzumab ozogamicin)

Revised

July 14, 2023

CC-0097

Vidaza (azacitidine)

Revised

July 14, 2023

CC-0129

Bavencio (avelumab)

Revised

July 14, 2023

CC-0090

Ixempra (ixabepilone)

Revised

July 14, 2023

*CC-0110

Perjeta (pertuzumab)

Revised

July 14, 2023

*CC-0115

Kadcyla (ado-trastuzumab)

Revised

July 14, 2023

CC-0124

Keytruda (pembrolizumab)

Revised

July 14, 2023

*CC-0062

Tumor Necrosis Factor Antagonists

Revised

July 14, 2023

CC-0165

Trodelvy (sacituzumab govitecan)

Revised

NVBCBS-CR-027766-23-CPN24010

PUBLICATIONS: July 2023 Provider Newsletter