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 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