Products & Programs PharmacyCommercialMay 1, 2025

Clinical Criteria updates for specialty pharmacy

The Anthem pre‑service clinical review of non‑oncology specialty pharmacy drugs will be managed by our Medical Specialty Drug Review team. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc.

To access the Clinical Criteria information, visit Clinical Criteria In Pharmacy.

New Clinical Criteria effective August 1, 2025:

  • CC-0275 Ziihera (zanidatamab‑hrii)
  • CC‑0276 Tryngolza (olezarsen)
  • CC‑0277 Vyalev (foscarbidopa/foslevodopa)

Revised Clinical Criteria effective August 1, 2025

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‑0058 Octreotide Agents
  • CC‑0063 Ustekinumab Agents (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Wezlana)
  • CC‑0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
  • CC‑0094 Pemetrexed (Alimta, Axtle, Pemfexy, Pemrydi)
  • CC‑0130 Imfinzi (durvalumab)
  • CC‑0185 Oxlumo (lumasiran)
  • CC‑0256 Rivfloza (nedosiran)

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Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: May 2025 Provider Newsletter