Clinical Criteria updates for specialty pharmacy

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

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

New Clinical Criteria effective September 1, 2025

• CC-0278 Unloxcyt (cosibelimab‑ipdl)
• CC‑0279 Datroway (datopotamab deruxtecan‑dlnk)
• CC‑0281 Opdivo Qvantig (nivolumab hyaluronidase‑nvhy)
• CC0282 Onapgo (apomorphine subcutaneous solution)

Revised Clinical Criteria effective September 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:

• CC0008 Subcutaneous Hormonal Implants
• CC‑0015 Infertility and HCG Agents
• CC‑0027 Denosumab
• CC‑0029 Dupixent (dupilumab)
• CC‑0037 Kanuma (sebelipase alfa)
• CC‑0050 Monoclonal Antibodies to Interleukin‑23
• CC‑0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non‑Oncologic Indications
• CC‑0063 Ustekinumab Agents (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Wezlana)
• CC‑0066 Monoclonal Antibodies to Interleukin‑6
• CC‑0119 Yervoy (ipilimumab)
• CC‑0121 Gazyva (obinutuzumab)
• CC‑0122 Arzerra (ofatumumab)
• CC‑0125 Opdivo (nivolumab)
• CC‑0149 Select Clotting Agents for Bleeding Disorders
• CC‑0158 Enhertu (fam‑trastuzumab deruxtecan‑nxki)
• CC‑0159 Scenesse (afamelanotide)
• CC‑0215 Ketamine injection (Ketalar)
• CC‑0261 Winrevair (sotatercept‑csrk)
• CC‑0267 Ebglyss (lebrikizumab‑lbkz)
• CC‑0269 Nemluvio (nemolizumab‑ilto)
• CC‑0272 Aucatzyl (obecabtagene autoleucel)