Products & Programs PharmacyCommercialAugust 1, 2024

Clinical Criteria updates for specialty pharmacy

The Medical Specialty Drug Review team for Anthem will manage the pre-service clinical review of non-oncology specialty pharmacy drugs. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc., a separate company.

The following Clinical Criteria documents were endorsed at the May 17, 2024, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective November 1, 2024

The following Clinical Criteria are new:

  • CC-0262 Tevimbra (tislelizumab-jsgr)

Revised Clinical Criteria effective November 1, 2024

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

  • CC-0002 Colony Stimulating Factor Agents
  • CC-0063 Ustekinumab Agents (Stelara, Selarsdi, Wezlana)
  • CC-0066 Monoclonal Antibodies to Interleukin-6
  • CC-0092 Adcetris (brentuximab vedotin)
  • CC-0098 Doxorubicin Liposome (Doxil)
  • CC-0105 Vectibix (panitumumab)
  • CC-0107 Bevacizumab for Non-ophthalmologic Indications
  • CC-0111 Nplate (romiplostim)
  • CC-0124 Keytruda (pembrolizumab)
  • CC-0130 Imfinzi (durvalumab)
  • CC-0162 Tepezza (teprotumumab-trbw)
  • CC-0188 Imcivree (setmelanotide)
  • CC-0199 Empaveli (pegcetacoplan)
  • CC-0221 Spevigo (spesolimab-sbzo)

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Commercial services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., or 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.

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PUBLICATIONS: August 2024 Provider Newsletter