Medicaid Managed CareJuly 23, 2024
Clinical Criteria updates
Effective August 22, 2024
Summary: On May 19, 2023, August 18, 2023, November 17, 2023, and February 23, 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. If you have 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 providers in 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 |
August 22, 2024 | *CC-0258 | iDoseTR (travoprost Implant) | New |
August 22, 2024 | *CC-0259 | Amtagvi (lifleucel) | New |
August 22, 2024 | *CC-0260 | Nexobrid (anacaulase-bcdb) | New |
August 22, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
August 22, 2024 | *CC-0041 | Complement Inhibitors | Revised |
August 22, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
August 22, 2024 | CC-0116 | Bendamustine agents | Revised |
August 22, 2024 | CC-0157 | Padcev (enfortumab vedotin) | Revised |
August 22, 2024 | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | Revised |
August 22, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised |
August 22, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised |
August 22, 2024 | *CC-0093 | Docetaxel (Taxotere) | Revised |
August 22, 2024 | *CC-0094 | Pemetrexed (Alimta, Pemfexy, Pemrydi) | Revised |
August 22, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
August 22, 2024 | *CC-0088 | Elzonris (tagraxofusp-erzs) | Revised |
August 22, 2024 | *CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
August 22, 2024 | *CC-0112 | Xofigo (Radium Ra 223 Dichloride) | Revised |
August 22, 2024 | *CC-0123 | Cyramza (ramucirumab) | Revised |
August 22, 2024 | *CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
August 22, 2024 | CC-0121 | Gazyva (obinutuzumab) | Revised |
August 22, 2024 | CC-0122 | Arzerra (ofatumumab) | Revised |
August 22, 2024 | *CC-0117 | Empliciti (elotuzumab) | Revised |
August 22, 2024 | *CC-0126 | Blincyto (blinatumomab) | Revised |
August 22, 2024 | CC-0113 | Sylvant (siltuximab) | Revised |
August 22, 2024 | CC-0110 | Perjeta (pertuzumab) | Revised |
August 22, 2024 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
August 22, 2024 | *CC-0108 | Halaven (eribulin) | Revised |
August 22, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
August 22, 2024 | *CC-0067 | Prostacyclin Infusion and Inhalation Therapy | Revised |
August 22, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
August 22, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
August 22, 2024 | *CC-0057 | Krystexxa (pegloticase) | Revised |
August 22, 2024 | *CC-0047 | Trogarzo | Revised |
August 22, 2024 | CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
August 22, 2024 | CC-0011 | Ocrevus (ocrelizumab) | Revised |
Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
OHBCBS-CD-062337-24
PUBLICATIONS: August 2024 Provider Newsletter
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