Medicaid Managed CareFebruary 6, 2025
Clinical Criteria updates
Effective March 10, 2025
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. 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 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 | ||
March 10, 2025 | CC-0266 | Rytelo (imetelstat) | New | ||
March 10, 2025 | CC-0156 | Reblozyl (luspatercept) | Revised
| ||
March 10, 2025 | CC-0244 | Columvi (glofitamab-gxbm) | Revised | ||
March 10, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised | ||
March 10, 2025 | CC-0104 | Levoleucovorin Agents | Revised | ||
March 10, 2025 | CC-0182 | Iron Agents | Revised | ||
March 10, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised | ||
March 10, 2025 | CC-0247 | Beyfortus (nirsevimab) | Revised | ||
March 10, 2025 | CC-0082 | Onpattro (patisiran) | Revised | ||
March 10, 2025 | CC-0217 | Amvuttra (vulrisiran) | Revised | ||
March 10, 2025 | CC-0084 | Tegsedi (inotersen) | Revised | ||
March 10, 2025 | CC-0209 | Leqvio (inclisiran) | Revised | ||
March 10, 2025 | CC-0193 | Evkeeza (evinacumab) | Revised | ||
March 10, 2025 | CC-0027 | Denosumab | Revised | ||
March 10, 2025 | CC-0019 | Zoledronic Acid | Revised | ||
March 10, 2025 | CC-0246 | Rystiggo (rozanolixizumab-noli) | Revised | ||
March 10, 2025 | CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised | ||
March 10, 2025 | CC-0028 | Benlysta (belimumab) | Revised | ||
March 10, 2025 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised | ||
March 10, 2025 | CC-0121 | Gazyva (obinutuzumab) | Revised | ||
March 10, 2025 | CC-0242 | Epkinly (epcoritamab-bysp) | Revised | ||
March 10, 2025 | CC-0130 | Imfinzi (durvalumab) | Revised | ||
March 10, 2025 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised | ||
March 10, 2025 | CC-0048 | Spinraza (nusinersen) | Revised | ||
March 10, 2025 | CC-0003 | Immunoglobulins | Revised | ||
March 10, 2025 | CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | 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-074703-24
PUBLICATIONS: March 2025 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/ohio/articles/clinical-criteria-updates-24026
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