Medicaid Managed CareMarch 25, 2024
Clinical Criteria updates — November 2023
On February 24, 2023, and November 17, 2023, 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
- 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 applies 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 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 |
April 25, 2024 | *CC-0252 | Adzynma (ADAMTS13, recombinant-krhn) | New |
April 25, 2024 | *CC-0253 | Aphexda (motixafortide) | New |
April 25, 2024 | *CC-0254 | Zilbysq (zilucoplan) | New |
April 25, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
April 25, 2024 | CC-0223 | Imjudo (tremelimumab-actl) | Revised |
April 25, 2024 | *CC-0059 | Selected Injectable NK-1 Antiemetic Agents | Revised |
April 25, 2024 | CC-0074 | Akynzeo (fosnetupitant and palonosetron) for injection | Revised |
April 25, 2024 | *CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
April 25, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
April 25, 2024 | CC-0150 | Kymriah (tisagenlecleucel) | Revised |
April 25, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
April 25, 2024 | CC-0133 | Aliqopa (copanlisib) | Revised |
April 25, 2024 | CC-0205 | Fyarro (sirolimus albumin bound) | Revised |
April 25, 2024 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
April 25, 2024 | *CC-0226 | Elahere (mirvetuximab) | Revised |
April 25, 2024 | CC-0125 | Opdivo (nivolumab) | Revised |
April 25, 2024 | CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | Revised |
April 25, 2024 | *CC-0009 | Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis | Revised |
April 25, 2024 | *CC-0014 | Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis |
Revised |
April 25, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
April 25, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
April 25, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
April 25, 2024 | *CC-0032 | Botulinum Toxin | Revised |
April 25, 2024 | *CC-0068 | Growth Hormone | Revised |
April 25, 2024 | *CC-0173 | Enspryng (satralizumab-mwge) | Revised |
April 25, 2024 | *CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
April 25, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
April 25, 2024 | *CC-0041 | Complement Inhibitors | Revised |
April 25, 2024 | *CC-0071 | Entyvio (vedolizumab) | Revised |
April 25, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
April 25, 2024 | *CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
April 25, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
April 25, 2024 | *CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
April 25, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
April 25, 2024 | *CC-0063 | Ustekinumab Agents | Revised |
April 25, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
April 25, 2024 | CC-0003 | Immunoglobulins | Revised |
April 25, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
April 25, 2024 | CC-0247 | Beyfortus (nirsevimab) | Revised |
April 25, 2024 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
April 25, 2024 | CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
April 25, 2024 | CC-0209 | Leqvio (inclisiran) | Revised |
April 25, 2024 | *CC-0086 | Spravato (esketamine) Nasal Spray | 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-052674-24
PUBLICATIONS: May 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/ohio/articles/clinical-criteria-updates-november-2023-18836-18836
Or scan this QR code with your phone