HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsFebruary 26, 2025
Clinical Criteria updates
Effective March 28, 2025
Summary: The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem HealthKeepers Plus members. 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
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 plan. 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 |
March 28, 2025 | CC-0272 | Aucatzyl (obecabtagene autoleucel) | New |
March 28, 2025 | CC-0273 | Vyloy (zolbetuximab-clzb) | New |
March 28, 2025 | CC-0223 | Imjudo (tremelimumab-actl) | Revised |
March 28, 2025 | CC-0056 | Selected Injectable 5HT3 Antiemetic Agents | Revised |
March 28, 2025 | CC-0148 | Agents for Hemophilia B | Revised |
March 28, 2025 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised |
March 28, 2025 | CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
March 28, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised |
March 28, 2025 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised |
March 28, 2025 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
March 28, 2025 | CC-0204 | Tivdak (tisotumab vedotin-tftv) | Revised |
March 28, 2025 | CC-0226 | Elahere (mirvetuximab) | Revised |
March 28, 2025 | CC-0125 | Opdivo (nivolumab) | Revised |
March 28, 2025 | CC-0128 | Tecentriq (atezolizumab) | Revised |
March 28, 2025 | CC-0011 | Ocrevus (ocrelizumab)/Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) | Revised |
March 28, 2025 | CC-0173 | Enspryng (satralizumab-mwge) | Revised |
March 28, 2025 | CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
March 28, 2025 | CC-0199 | Empaveli (pegcetacoplan) | Revised |
March 28, 2025 | CC-0041 | Complement Inhibitors | Revised |
March 28, 2025 | CC-0071 | Entyvio (vedolizumab) | Revised |
March 28, 2025 | CC-0064 | Interleukin-1 Inhibitors | Revised |
March 28, 2025 | CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
March 28, 2025 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
March 28, 2025 | CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
March 28, 2025 | CC-0078 | Orencia (abatacept) | Revised |
March 28, 2025 | CC-0063 | Ustekinumab Agents | Revised |
March 28, 2025 | CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
March 28, 2025 | CC-0003 | Immunoglobulins | Revised |
March 28, 2025 | CC-0073 | Alpha-1 Proteinase Inhibitor Therapy | Revised |
March 28, 2025 | CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
March 28, 2025 | CC-0029 | Dupixent (dupilumab) | Revised |
March 28, 2025 | CC-0105 | Vectibix (panitumumab) | Revised |
March 28, 2025 | CC-0095 | Bortezomib (Boruzu, Velcade) | Revised |
March 28, 2025 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
March 28, 2025 | CC-0201 | Rybrevant (amivantamab-vmjw) | Revised |
March 28, 2025 | CC-0120 | Kyprolis (carfilzomib) | Revised |
March 28, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
March 28, 2025 | CC-0255 | Loqtorzi (toripalimab-tpzi) | Revised |
March 28, 2025 | CC-0001 | Erythropoiesis Stimulating Agents | Revised |
March 28, 2025 | CC-0002 | Colony Stimulating Factor 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-076593-25-CPN76226
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Visit https://providernews.anthem.com/virginia/articles/clinical-criteria-updates-24315
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