Medicare AdvantageSeptember 3, 2024
Clinical Criteria updates
Effective October 6, 2024
Summary: On June 10, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for BMA. 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 BMA 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-0263 | Imdelltra (tarlatamab-dlle) | New |
October 6, 2024 | *CC-0264 | Anktiva (nogapendekin alfa inbekicept-pmln) | New |
October 6, 2024 | *CC-0265 | Kisunla (donanemab) | New |
October 6, 2024 | *CC-0166 | Trastuzumab Agents | Revised |
October 6, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
October 6, 2024 | CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
October 6, 2024 | CC-0094 | Pemetrexed (Alimta, Pemfexy, Pemrydi) | Revised |
October 6, 2024 | CC-0032 | Botulinum Toxin | Revised |
October 6, 2024 | *CC-0041 | Complement C5 Inhibitors | Revised |
Blue Medicare Advantage is the trade name of Group Retiree Health Solutions, Inc., an independent licensee of the Blue Cross Blue Shield Association.
PAIBC-CR-063980-24-CPN63395
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Visit https://providernews.anthem.com/pennsylvania/articles/clinical-criteria-updates-21721
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