Virginia
Provider Communications
Medical drug benefit Clinical Criteria updates
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 March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the Anthem HealthKeepers Plus 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. If you have questions or would like 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.
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 |
|
July 16, 2021 |
*ING-CC-0195* |
Abecma (idecabtagene vicleucel) |
New |
|
July 16, 2021 |
*ING-CC-0191* |
Pepaxto (melphalan flufenamide; melflufen) |
New |
|
July 16, 2021 |
*ING-CC-0192* |
Cosela (trilaciclib) |
New |
|
July 16, 2021 |
*ING-CC-0193* |
Evkeeza (evinacumab) |
New |
|
July 16, 2021 |
*ING-CC-0194* |
Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection |
New |
|
July 16, 2021 |
ING-CC-0125 |
Opdivo (nivolumab) |
Revised |
|
July 16, 2021 |
*ING-CC-0159* |
Scenesse (afamelanotide) |
Revised |
|
July 16, 2021 |
ING-CC-0151 |
Yescarta (axicabtagene ciloleucel) |
Revised |
|
July 16, 2021 |
*ING-CC-0145* |
Libtayo (cemiplimab-rwlc) |
Revised |
|
July 16, 2021 |
*ING-CC-0130* |
Imfinzi (durvalumab) |
Revised |
|
July 16, 2021 |
ING-CC-0127 |
Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) |
Revised |
|
July 16, 2021 |
*ING-CC-0075* |
Rituximab Agents for Non-Oncologic Indications |
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.
Featured In:
July 2021 Anthem Provider News - Virginia