HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsNovember 15, 2024
Clinical Criteria updates
Effective December 18, 2024
Summary:
On August 16, 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 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.
- This notice is meant to inform the provider of new or revised criteria that has 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 18, 2024 | *CC-0266 | Rytelo (imetelstat) | New |
December 18, 2024 | CC-0156 | Reblozyl (luspatercept) | Revised
|
December 18, 2024 | CC-0244 | Columvi (glofitamab-gxbm) | Revised |
December 18, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
December 18, 2024 | CC-0104 | Levoleucovorin Agents | Revised |
December 18, 2024 | CC-0182 | Iron Agents | Revised |
December 18, 2024 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
December 18, 2024 | CC-0247 | Beyfortus (nirsevimab) | Revised |
December 18, 2024 | *CC-0007 | Synagis (palivizumab) | Revised |
December 18, 2024 | *CC-0082 | Onpattro (patisiran) | Revised |
December 18, 2024 | *CC-0217 | Amvuttra (vulrisiran) | Revised |
December 18, 2024 | *CC-0084 | Tegsedi (inotersen) | Revised |
December 18, 2024 | *CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
December 18, 2024 | CC-0209 | Leqvio (inclisiran) | Revised |
December 18, 2024 | *CC-0193 | Evkeeza (evinacumab) | Revised |
December 18, 2024 | *CC-0027 | Denosumab | Revised |
December 18, 2024 | CC-0019 | Zoledronic Acid | Revised |
December 18, 2024 | CC-0208 | Adbry (tralokinumab) | Revised |
December 18, 2024 | *CC-0029 | Dupixent (dupilumab) | Revised |
December 18, 2024 | *CC-0246 | Rystiggo (rozanolixizumab-noli) | Revised |
December 18, 2024 | *CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised |
December 18, 2024 | *CC-0028 | Benlysta (belimumab) | Revised |
December 18, 2024 | *CC-0194 | Cabenuva (cabotegravir extended-release; rilpivirine extended -release) injection | Revised |
December 18, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
December 18, 2024 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
December 18, 2024 | CC-0121 | Gazyva (obinutuzumab) | Revised |
December 18, 2024 | CC-0242 | Epkinly (epcoritamab-bysp) | Revised |
December 18, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
December 18, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
December 18, 2024 | CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
December 18, 2024 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
December 18, 2024 | CC-0071 | Entyvio (vedolizumab) | Revised |
December 18, 2024 | *CC-0048 | Spinraza (nusinersen) | Revised |
December 18, 2024 | *CC-0003 | Immunoglobulins | Revised |
December 18, 2024 | *CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide 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-070794-24-CPN70546
PUBLICATIONS: December 2024 Provider Newsletter
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Visit https://providernews.anthem.com/virginia/articles/clinical-criteria-updates-22946
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