Policy UpdatesMedicaidJune 30, 2023

Clinical Criteria Updates - September 2022

Clinical Criteria updates

Summary: On May 20, 2022, August 19, 2022, and September 22, 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 6, 2023

*ING-CC-0018

Pompe Disease

Revised

August 6, 2023

*ING-CC-0017

Xiaflex (collagenase clostridium histolyticum)

Revised

August 6, 2023

ING-CC-0174

Kesimpta (ofatumumab)

Revised

August 6, 2023

ING-CC-0089

Mozobil (plerixafor)

Revised

August 6, 2023

ING-CC-0158

Enhertu (fam-trastuzumab deruxtecan-nxki)

Revised

August 6, 2023

ING-CC-0130

Imfinzi (durvalumab)

Revised

August 6, 2023

ING-CC-0097

Vidaza (azacitidine)

Revised

August 6, 2023

*ING-CC-0072

Vascular Endothelial Growth Factor Inhibitors

Revised

August 6, 2023

ING-CC-0063

Stelara (ustekinumab)

Revised

August 6, 2023

*ING-CC-0002

Colony Stimulating Factor Agents

Revised

August 6, 2023

*ING-CC-0107

Bevacizumab for non-ophthalmologic indications

Revised

August 6, 2023

*ING-CC-0166

Trastuzumab Agents

Revised

NVBCBS-CD-013906-22

PUBLICATIONS: August 2023 Provider Newsletter