Medicaid Managed CareMarch 27, 2025
Clinical Criteria updates
Effective May 1, 2025
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 apply 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 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 |
May 1, 2025 | CC-0272 | Aucatzyl (obecabtagene autoleucel) | New |
May 1, 2025 | CC-0273 | Vyloy (zolbetuximab-clzb) | New |
May 1, 2025 | CC-0223 | Imjudo (tremelimumab-actl) | Revised |
May 1, 2025 | CC-0056 | Selected Injectable 5HT3 Antiemetic Agents | Revised |
May 1, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised |
May 1, 2025 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised |
May 1, 2025 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
May 1, 2025 | CC-0204 | Tivdak (tisotumab vedotin-tftv) | Revised |
May 1, 2025 | CC-0226 | Elahere (mirvetuximab) | Revised |
May 1, 2025 | CC-0125 | Opdivo (nivolumab) | Revised |
May 1, 2025 | CC-0128 | Tecentriq (atezolizumab) | Revised |
May 1, 2025 | CC-0173 | Enspryng (satralizumab-mwge) | Revised |
May 1, 2025 | CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
May 1, 2025 | CC-0199 | Empaveli (pegcetacoplan) | Revised |
May 1, 2025 | CC-0041 | Complement Inhibitors | Revised |
May 1, 2025 | CC-0003 | Immunoglobulins | Revised |
May 1, 2025 | CC-0073 | Alpha-1 Proteinase Inhibitor Therapy | Revised |
May 1, 2025 | CC-0105 | Vectibix (panitumumab) | Revised |
May 1, 2025 | CC-0095 | Bortezomib (Boruzu, Velcade) | Revised |
May 1, 2025 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
May 1, 2025 | CC-0201 | Rybrevant (amivantamab-vmjw) | Revised |
May 1, 2025 | CC-0120 | Kyprolis (carfilzomib) | Revised |
May 1, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
May 1, 2025 | CC-0255 | Loqtorzi (toripalimab-tpzi) | 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-078011-25
PUBLICATIONS: April 2025 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/ohio/articles/clinical-criteria-updates-24680
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