Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

On November 19, 2021, December 13, 2021, and January 10, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for
HealthKeepers, Inc. 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 members of 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.

 

Effective date

Document number

Clinical Criteria title

New or revised

April 8, 2022

*ING-CC-0205

Fyarro (sirolimus albumin bound)

New

April 8, 2022

*ING-CC-0206

Besremi (ropeginterferon alfa-2b-njft)

New

April 8, 2022

*ING-CC-0207

Vyvgart (efgartigimod alfa-fcab)

New

April 8, 2022

*ING-CC-0208

Adbry (tralokinumab)

New

April 8, 2022

*ING-CC-0209

Leqvio (inclisiran)

New

April 8, 2022

ING-CC-0124

Keytruda (pembrolizumab)

Revised

April 8, 2022

ING-CC-0079

Strensiq (Asfotase Alfa)

Revised

April 8, 2022

ING-CC-0102

Gonadotropin releasing hormone (GNRH)  Analogs for Oncologic Indications

Revised

April 8, 2022

ING-CC-0168

Tecartus (brexucabtagene autoleucel)

Revised

April 8, 2022

*ING-CC-0004

Repository Corticotropin Injection

Revised

April 8, 2022

ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Revised

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

 

AVA-NU-0556-22



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April 2022 Anthem Provider News - Virginia