MedicaidMay 29, 2024
Clinical Criteria updates
Effective June 29, 2024
Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 2024, 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 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 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 |
June 29, 2024 | *CC-0258 | iDoseTR (travoprost Implant) | New |
June 29, 2024 | *CC-0259 | Amtagvi (lifleucel) | New |
June 29, 2024 | *CC-0260 | Nexobrid (anacaulase-bcdb) | New |
June 29, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
June 29, 2024 | *CC-0041 | Complement Inhibitors | Revised |
June 29, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
June 29, 2024 | CC-0116 | Bendamustine agents | Revised |
June 29, 2024 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
June 29, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
June 29, 2024 | CC-0157 | Padcev (enfortumab vedotin) | Revised |
June 29, 2024 | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | Revised |
June 29, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised |
June 29, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised |
June 29, 2024 | *CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
June 29, 2024 | *CC-0093 | Docetaxel (Taxotere) | Revised |
June 29, 2024 | *CC-0094 | Pemetrexed (Alimta, Pemfexy, Pemrydi) | Revised |
June 29, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
June 29, 2024 | *CC-0088 | Elzonris (tagraxofusp-erzs) | Revised |
June 29, 2024 | *CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
June 29, 2024 | *CC-0112 | Xofigo (Radium Ra 223 Dichloride) | Revised |
June 29, 2024 | *CC-0123 | Cyramza (ramucirumab) | Revised |
June 29, 2024 | *CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
June 29, 2024 | CC-0121 | Gazyva (obinutuzumab) | Revised |
June 29, 2024 | CC-0122 | Arzerra (ofatumumab) | Revised |
June 29, 2024 | CC-0232 | Lunsumio (mosunetuzumab-axgb) | Revised |
June 29, 2024 | CC-0109 | Zaltrap (ziv-aflibercept) | Revised |
June 29, 2024 | CC-0135 | Melanoma Vaccines | Revised |
June 29, 2024 | *CC-0096 | Asparagine Specific Enzymes | Revised |
June 29, 2024 | CC-0120 | Kyprolis (carfilzomib) | Revised |
June 29, 2024 | *CC-0117 | Empliciti (elotuzumab) | Revised |
June 29, 2024 | *CC-0126 | Blincyto (blinatumomab) | Revised |
June 29, 2024 | CC-0113 | Sylvant (siltuximab) | Revised |
June 29, 2024 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
June 29, 2024 | CC-0097 | Vidaza (azacitidine) | Revised |
June 29, 2024 | CC-0129 | Bavencio (avelumab) | Revised |
June 29, 2024 | *CC-0090 | Ixempra (ixabepilone) | Revised |
June 29, 2024 | CC-0110 | Perjeta (pertuzumab) | Revised |
June 29, 2024 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
June 29, 2024 | *CC-0108 | Halaven (eribulin) | Revised |
June 29, 2024 | CC-0089 | Mozobil (plerixafor) | Revised |
June 29, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
June 29, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
June 29, 2024 | *CC-0212 | Tezspire (tezepelumab-ekko) | Revised |
June 29, 2024 | *CC-0033 | Xolair (omalizumab) | Revised |
June 29, 2024 | *CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
June 29, 2024 | *CC-0029 | Dupixent (dupilumab) | Revised |
June 29, 2024 | *CC-0208 | Adbry (tralokinumab) | Revised |
June 29, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
June 29, 2024 | *CC-0067 | Prostacyclin Infusion and Inhalation Therapy | Revised |
June 29, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
June 29, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
June 29, 2024 | *CC-0057 | Krystexxa (pegloticase) | Revised |
June 29, 2024 | *CC-0068 | Growth Hormones | Revised |
June 29, 2024 | *CC-0047 | Trogarzo | Revised |
June 29, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
June 29, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
June 29, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
June 29, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
NYBCBS-CD-059009-24-CPN57972
PUBLICATIONS: July 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/new-york/articles/clinical-criteria-updates-19883
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