Clinical Criteria updates

Summary:

The Pharmacy and Therapeutics (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. For 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

Please share this notice with other members of 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 plan. 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
March 1, 2025	CC-0267	Ebglyss (lebrikizumab-lbkz)	New
March 1, 2025	CC-0268	Lymphir (denileukin diftitox-cxdl)	New
March 1, 2025	CC-0269	Nemluvio (nemolizumab-ilto)	New
March 1, 2025	CC-0270	Niktimvo (axatilmab-csfr)	New
March 1, 2025	CC-0271	Tecelra (afamitresgene autoleucel)	New
March 1, 2025	CC-0011	Ocrevus (ocrelizumab)/ Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq)	Revised
March 1, 2025	CC-0012	Brineura (cerliponase alfa)	Revised
March 1, 2025	CC-0072	Vascular Endothelial Growth Factor (VEGF) Inhibitors	Revised
March 1, 2025	CC-0130	Imfinzi (durvalumab)	Revised
March 1, 2025	CC-0201	Rybrevant (amivantamab-ymjw)	Revised
March 1, 2025	CC-0250	Veopoz (pozelimab-bbfg)	Revised