Medicaid Managed CareSeptember 3, 2024
Clinical Criteria updates
This article was updated on November 18, 2024, to remove Clinical Criteria CC-0043.
Summary: On May 17, 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 need 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 apply 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 have 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 |
October 6, 2024 | *CC-0262 | Tevimbra (tislelizumab-jsgr) | New |
October 6, 2024 | *CC-0162 | Tepezza (teprotumumab-trbw) | Revised |
October 6, 2024 | *CC-0111 | Nplate (romiplostim) | Revised |
October 6, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
October 6, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
October 6, 2024 | *CC-0098 | Doxorubicin Liposome (Doxil, Lipodox) | Revised |
October 6, 2024 | *CC-0101 | Torisel (temsirolimus) | Revised |
October 6, 2024 | *CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
October 6, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
October 6, 2024 | *CC-0092 | Adcetris (brentuximab vedotin) | Revised |
October 6, 2024 | CC-0106 | Erbitux (cetuximab) | Revised |
October 6, 2024 | *CC-0105 | Vectibix (panitumumab) | Revised |
October 6, 2024 | CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
October 6, 2024 | CC-0160 | Vyepti (eptinezumab) | Revised |
October 6, 2024 | CC-0102 | GNRH Analogs for Oncologic Indications | Revised |
October 6, 2024 | CC-0201 | Rybrevant (amivantamab-ymjw) | Revised |
October 6, 2024 | *CC-0188 | Imcivree (setmelanotide) | Revised |
October 6, 2024 | *CC-0124 | Keytruda (pembrolizumab) | Revised |
October 6, 2024 | CC-0041 | Complement C5 Inhibitors | Revised |
October 6, 2024 | CC-0199 | Empaveli (pegcetacoplan) | Revised |
October 6, 2024 | *CC-0130 | Imfinzi (durvalumab) | Revised |
October 6, 2024 | CC-0240 | Zynyz (retifanlimab-dlwr) | Revised |
October 6, 2024 | CC-0123 | Cyramza (ramucirumab) | Revised |
October 6, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
October 6, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
October 6, 2024 | CC-0226 | Elahere (mirvetuximab) | Revised |
October 6, 2024 | CC-0221 | Spevigo (spesolimab-sbzo) | 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-066365-24, OHBCBS-CD-072786-24
PUBLICATIONS: October 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/ohio/articles/clinical-criteria-updates-21722
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