MedicaidOctober 23, 2023
Clinical Criteria updates - June 2023
Medical drug benefit Clinical Criteria updates
On August 19, 2022, September 12, 2022, February 24, 2023, May 19, 2023, June 12, 2023, and July 11, 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 Healthcare Solutions (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 would like 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.
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 |
November 26, 2023 | *CC-0243 | Vyjuvek (beremagene geperpavec) | New |
November 26, 2023 | *CC-0242 | Epkinly (epcoritamab-bysp) | New |
November 26, 2023 | *CC-0241 | Elfabrio (pegunigalsidase alfa-iwxj) | New |
November 26, 2023 | CC-0228 | Leqembi (lecanemab) | Revised |
November 26, 2023 | *CC-0061 | Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications | Revised |
November 26, 2023 | *CC-0015 | Infertility and HCG Agents | Revised |
November 26, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
November 26, 2023 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised |
November 26, 2023 | *CC-0177 | Zilretta (triamcinolone acetonide extended-release) | Revised |
November 26, 2023 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised |
November 26, 2023 | CC-0032 | Botulinum Toxin | Revised |
November 26, 2023 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
November 26, 2023 | *CC-0001 | Erythropoiesis Stimulating Agents | Revised |
November 26, 2023 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
November 26, 2023 | *CC-0209 | Leqvio (inclisiran) | Revised |
November 26, 2023 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
NVBCBS-CD-036881-23-CPN36110
PUBLICATIONS: November 2023 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/nevada/articles/clinical-criteria-updates-june-2023-16339-16339
Or scan this QR code with your phone