MedicaidJune 26, 2024
Clinical Criteria updates — November 2023
Summary
On February 24, 2023, and November 17, 2023, the Pharmacy and Therapeutic (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 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 | Clinical Criteria number | Clinical Criteria title | New or revised |
August 1, 2024 | *CC-0252 | Adzynma (ADAMTS13, recombinant-krhn) | New |
August 1, 2024 | *CC-0253 | Aphexda (motixafortide) | New |
August 1, 2024 | *CC-0254 | Zilbysq (zilucoplan) | New |
August 1, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
August 1, 2024 | CC-0223 | Imjudo (tremelimumab-actl) | Revised |
August 1, 2024 | *CC-0059 | Selected Injectable NK-1 Antiemetic Agents | Revised |
August 1, 2024 | CC-0074 | Akynzeo (fosnetupitant and palonosetron) for injection | Revised |
August 1, 2024 | *CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
August 1, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
August 1, 2024 | CC-0150 | Kymriah (tisagenlecleucel) | Revised |
August 1, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
August 1, 2024 | CC-0133 | Aliqopa (copanlisib) | Revised |
August 1, 2024 | CC-0205 | Fyarro (sirolimus albumin bound) | Revised |
August 1, 2024 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
August 1, 2024 | *CC-0226 | Elahere (mirvetuximab) | Revised |
August 1, 2024 | CC-0125 | Opdivo (nivolumab) | Revised |
August 1, 2024 | CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | Revised |
August 1, 2024 | *CC-0009 | Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis | Revised |
August 1, 2024 | *CC-0014 | Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis |
Revised |
August 1, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
August 1, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
August 1, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
August 1, 2024 | *CC-0032 | Botulinum Toxin | Revised |
August 1, 2024 | *CC-0068 | Growth Hormone | Revised |
August 1, 2024 | *CC-0173 | Enspryng (satralizumab-mwge) | Revised |
August 1, 2024 | *CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
August 1, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
August 1, 2024 | *CC-0041 | Complement Inhibitors | Revised |
August 1, 2024 | *CC-0071 | Entyvio (vedolizumab) | Revised |
August 1, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
August 1, 2024 | *CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
August 1, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
August 1, 2024 | *CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
August 1, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
August 1, 2024 | *CC-0063 | Ustekinumab Agents | Revised |
August 1, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
August 1, 2024 | CC-0003 | Immunoglobulins | Revised |
August 1, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
August 1, 2024 | CC-0247 | Beyfortus (nirsevimab) | Revised |
August 1, 2024 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
August 1, 2024 | CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
August 1, 2024 | CC-0209 | Leqvio (inclisiran) | Revised |
August 1, 2024 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
NVBCBS-CD-050624-24-CPN49889
PUBLICATIONS: August 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/nevada/articles/clinical-criteria-updates-november-2023-20640
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