Anthem clinical criteria updates for specialty pharmacy are available
Effective for dates of service on and after May 1, 2021, the following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require prior authorization by AIM Specialty Health® (AIM), a separate company. This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
Access the clinical criteria document information
- ING-CC-0003 Immunoglobulins
- ING-CC-0011 Ocrevus (ocrelizumab)
- ING-CC-0041 Complement Inhibitors
- ING-CC-0048 Spinraza (nusinersen)
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0063 Stelara (ustekinumab)
- ING-CC-0071 Entyvio (vedolizumab)
- ING-CC-0121 Gazyva (obinutuzumab)
- ING-CC-0174 Kesimpta (ofatumumab)
- ING-CC-0183 Sogroya (somapacitan-beco)
February 2021 Anthem Provider News - Virginia