Medicare AdvantageMay 11, 2023
Clinical Criteria Updates February 2023
Summary: On February 24, 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. 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 Blue Cross and Blue Shield 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 |
June 18, 2023 | *CC-0232 | Lunsumio (mosunetuzumab-axgb) | New |
June 18, 2023 | *CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | New |
June 18, 2023 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | New |
June 18, 2023 | *CC-0234 | Syfovre (pegcetacoplan) | New |
June 18, 2023 | *CC-0231 | Lamzede (velmanase alfa-tycv) | New |
June 18, 2023 | CC-0007 | Synagis (palivizumab) | Revised |
June 18, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
June 18, 2023 | CC-0210 | Enjaymo (sutimlimab-jome) | Revised |
June 18, 2023 | *CC-0128 | Tecentriq (atezolizumab) | Revised |
June 18, 2023 | *CC-0116 | Bendamustine agents | Revised |
June 18, 2023 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
June 18, 2023 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
June 18, 2023 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
June 18, 2023 | *CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
June 18, 2023 | CC-0125 | Opdivo (nivolumab) | Revised |
June 18, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised |
June 18, 2023 | CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
June 18, 2023 | *CC-0093 | Docetaxel (Taxotere) | Revised |
June 18, 2023 | CC-0094 | Pemetrexed Agents (Alimta, Pemfexy) | Revised |
June 18, 2023 | CC-0130 | Imfinzi (durvalumab) | Revised |
June 18, 2023 | CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
June 18, 2023 | CC-0123 | Cyramza (ramucirumab) | Revised |
June 18, 2023 | CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
June 18, 2023 | CC-0121 | Gazyva (obinutuzumab) | Revised |
June 18, 2023 | *CC-0096 | Asparagine Specific Enzymes | Revised |
June 18, 2023 | *CC-0120 | Kyprolis (carfilzomib) | Revised |
June 18, 2023 | CC-0117 | Empliciti (elotuzumab) | Revised |
June 18, 2023 | CC-0126 | Blincyto (blinatumomab) | Revised |
June 18, 2023 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
June 18, 2023 | CC-0097 | Vidaza (azacitidine) | Revised |
June 18, 2023 | CC-0129 | Bavencio (avelumab) | Revised |
June 18, 2023 | CC-0090 | Ixempra (ixabepilone) | Revised |
June 18, 2023 | *CC-0110 | Perjeta (pertuzumab) | Revised |
June 18, 2023 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
June 18, 2023 | CC-0124 | Keytruda (pembrolizumab) | Revised |
June 18, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
June 18, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
MULTI-BCBS-CR-024396-23-CPN24010
PUBLICATIONS: June 2023 Provider Newsletter
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