Policy UpdatesMedicaid Managed CareAugust 1, 2024

Clinical Criteria updates

Effective September 7, 2024

Summary: On 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

September 7, 2024

CC-0161

Sarclisa (isatuximab-irfc)

Revised

September 7, 2024

CC-0120

Kyprolis (carfilzomib)

Revised

September 7, 2024

CC-0132

Mylotarg (gemtuzumab ozogamicin)

Revised

September 7, 2024

CC-0129

Bavencio (avelumab)

Revised

September 7, 2024

CC-0124

Keytruda (pembrolizumab)

Revised

September 7, 2024

*CC-0078

Orencia (abatacept)

Revised

September 7, 2024

*CC-0090

Ixempra (ixabepilone)

Revised

September 7, 2024

*CC-0096

Asparagine Specific Enzymes

Revised

September 7, 2024

CC-0097

Vidaza (azacitidine)

Revised

September 7, 2024

*CC-0099

Abraxane (paclitaxel, protein bound)

Revised

September 7, 2024

CC-0109

Zaltrap (ziv-aflibercept)

Revised

September 7, 2024

CC-0158

Enhertu (fam-trastuzumab deruxtecan-nxki)

Revised

September 7, 2024

CC-0232

Lunsumio (mosunetuzumab-axgb)

Revised

September 7, 2024

CC-0135

Melanoma Vaccines

Revised

September 7, 2024

CC-0089

Mozobil (plerixafor)

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-063122-24

PUBLICATIONS: September 2024 Provider Newsletter