Policy UpdatesMedicaidOctober 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