Policy UpdatesMedicare AdvantageMay 11, 2023

Clinical Criteria Updates February 2023

Clinical Criteria Updates

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