Products & Programs PharmacyCommercialNovember 1, 2024

Clinical Criteria updates for specialty pharmacy

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

Visit the Clinical Criteria in pharmacy website to access Clinical Criteria information.

Coding updates effective February 15, 2025

Due to updates in the coding for the claims system, the claim system edits for the following Clinical Criteria will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination:

  • CC-0062 Tumor Necrosis Factor Antagonists
  • CC-0214 Carvykti (ciltacabtagene autoleucel)
  • CC-0259 Amtagvi (lifleucel)

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.

NYBCBS-CM-069959-24

PUBLICATIONS: November 2024 Provider Newsletter