Policy UpdatesMedicaidNovember 15, 2024

Clinical Criteria updates

Effective December 18, 2024

Summary:

On August 16, 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. 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 members of 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

December 18, 2024

*CC-0266

Rytelo (imetelstat)

New

December 18, 2024

CC-0156

Reblozyl (luspatercept)

Revised

December 18, 2024

CC-0244

Columvi (glofitamab-gxbm)

Revised

December 18, 2024

CC-0124

Keytruda (pembrolizumab)

Revised

December 18, 2024

CC-0104

Levoleucovorin Agents

Revised

December 18, 2024

CC-0182

Iron Agents

Revised

December 18, 2024

CC-0197

Jemperli (dostarlimab-gxly)

Revised

December 18, 2024

CC-0247

Beyfortus (nirsevimab)

Revised

December 18, 2024

*CC-0007

Synagis (palivizumab)

Revised

December 18, 2024

*CC-0082

Onpattro (patisiran)

Revised

December 18, 2024

*CC-0217

Amvuttra (vulrisiran)

Revised

December 18, 2024

*CC-0084

Tegsedi (inotersen)

Revised

December 18, 2024

*CC-0010

Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors

Revised

December 18, 2024

CC-0209

Leqvio (inclisiran)

Revised

December 18, 2024

*CC-0193

Evkeeza (evinacumab)

Revised

December 18, 2024

*CC-0027

Denosumab

Revised

December 18, 2024

CC-0019

Zoledronic Acid

Revised

December 18, 2024

CC-0208

Adbry (tralokinumab)

Revised

December 18, 2024

*CC-0029

Dupixent (dupilumab)

Revised

December 18, 2024

*CC-0246

Rystiggo (rozanolixizumab-noli)

Revised

December 18, 2024

*CC-0207

Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)

Revised

December 18, 2024

*CC-0028

Benlysta (belimumab)

Revised

December 18, 2024

*CC-0194

Cabenuva (cabotegravir extended-release; rilpivirine extended -release) injection

Revised

December 18, 2024

*CC-0002

Colony Stimulating Factor Agents

Revised

December 18, 2024

CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

December 18, 2024

CC-0121

Gazyva (obinutuzumab)

Revised

December 18, 2024

CC-0242

Epkinly (epcoritamab-bysp)

Revised

December 18, 2024

CC-0130

Imfinzi (durvalumab)

Revised

December 18, 2024

CC-0158

Enhertu (fam-trastuzumab deruxtecan-nxki)

Revised

December 18, 2024

CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

December 18, 2024

CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

December 18, 2024

CC-0071

Entyvio (vedolizumab)

Revised

December 18, 2024

*CC-0048

Spinraza (nusinersen)

Revised

December 18, 2024

*CC-0003

Immunoglobulins

Revised

December 18, 2024

*CC-0058

Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents

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-070789-24-CPN70546