Policy UpdatesMedicare AdvantageMay 4, 2023

Clinical Criteria Updates December 2022

Clinical Criteria updates

On August 19, 2022, December 12, 2022, and January 12, 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. 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 need 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 Blue Cross and Blue Shieldonly. 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

June 9, 2023

*CC-0226

Elahere (mirvetuximab)

New

June 9, 2023

*CC-0227

Briumvi (ublituximab)

New

June 9, 2023

*CC-0228

Leqembi (lecanemab)

New

June 9, 2023

*CC-0229

Sunlenca (lenacapavir)

New

June 9, 2023

CC-0029

Dupixent (dupilumab)

Revised

June 9, 2023

CC-0185

Oxlumo (lumasiran)

Revised

June 9, 2023

*CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Inhibitors

Revised

June 9, 2023

CC-0130

Imfinzi (durvalumab)

Revised

June 9, 2023

CC-0223

Imjudo (tremelimumab-actl)

Revised

June 9, 2023

CC-0145

Libtayo (cemiplimab-rwlc)

Revised

June 9, 2023

CC-0092

Adcetris (brentuximab vedotin)

Revised

June 9, 2023

CC-0128

Tecentriq (atezolizumab)

Revised

June 9, 2023

*CC-0182

Iron Agents

Revised

MULTI-BCBS-CR-019965-23-CPN19551

PUBLICATIONS: June 2023 Provider Newsletter