HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsNovember 7, 2024
Clinical Criteria updates
Effective December 11, 2024
Summary: On May 17, 2024, the Pharmacy and Therapeutic (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 providers in your practice and office staff.
Please note:
- The Clinical Criteria listed below apply 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 have been adopted by HealthKeepers, Inc. 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 |
December 11, 2024 | *CC-0262 | Tevimbra (tislelizumab-jsgr) | New |
December 11, 2024 | *CC-0162 | Tepezza (teprotumumab-trbw) | Revised |
December 11, 2024 | *CC-0111 | Nplate (romiplostim) | Revised |
December 11, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
December 11, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
December 11, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised |
December 11, 2024 | *CC-0098 | Doxorubicin Liposome (Doxil, Lipodox) | Revised |
December 11, 2024 | *CC-0101 | Torisel (temsirolimus) | Revised |
December 11, 2024 | *CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
December 11, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
December 11, 2024 | *CC-0092 | Adcetris (brentuximab vedotin) | Revised |
December 11, 2024 | CC-0106 | Erbitux (cetuximab) | Revised |
December 11, 2024 | *CC-0105 | Vectibix (panitumumab) | Revised |
December 11, 2024 | CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
December 11, 2024 | CC-0160 | Vyepti (eptinezumab) | Revised |
December 11, 2024 | CC-0102 | GNRH Analogs for Oncologic Indications | Revised |
December 11, 2024 | CC-0201 | Rybrevant (amivantamab-ymjw) | Revised |
December 11, 2024 | *CC-0188 | Imcivree (setmelanotide) | Revised |
December 11, 2024 | *CC-0124 | Keytruda (pembrolizumab) | Revised |
December 11, 2024 | CC-0041 | Complement C5 Inhibitors | Revised |
December 11, 2024 | CC-0199 | Empaveli (pegcetacoplan) | Revised |
December 11, 2024 | *CC-0130 | Imfinzi (durvalumab) | Revised |
December 11, 2024 | CC-0240 | Zynyz (retifanlimab-dlwr) | Revised |
December 11, 2024 | CC-0123 | Cyramza (ramucirumab) | Revised |
December 11, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
December 11, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
December 11, 2024 | CC-0226 | Elahere (mirvetuximab) | Revised |
December 11, 2024 | CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
December 11, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
December 11, 2024 | CC-0221 | Spevigo (spesolimab-sbzo) | Revised |
December 11, 2024 | CC-0071 | Entyvio (vedolizumab) | Revised |
December 11, 2024 | *CC-0063 | Ustekinumab Agents | Revised |
HealthKeepers, Inc. is an independent licensee of the Blue Cross Blue Shield Association. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
VABCBS-CD-063683-24-CPN63281
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