Policy UpdatesMedicaid Managed CareSeptember 3, 2024

Clinical Criteria updates

Effective October 6, 2024

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