Guideline Updates Coverage and Clinical GuidelinesHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMarch 18, 2024

Clinical Criteria updates — December 2023

Summary: On December 11, 2023, and January 5, 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. If you have questions or need 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 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

April 18, 2024

*CC-0255

Loqtorzi (toripalimab-tpzi)

New

April 18, 2024

*CC-0256

Rivfloza (nedosiran)

New

April 18, 2024

*CC-0257

Wainua (eplontersen)

New

April 18, 2024

*CC-0185

Oxlumo (lumasiran)

Revised

April 18, 2024

*CC-0107

Bevacizumab for Non-ophthalmologic Indications

Revised

April 18, 2024

*CC-0002

Colony Stimulating Factor Agents

Revised

April 18, 2024

CC-0075

Rituximab Agents for Non-Oncologic Indications

Revised

April 18, 2024

CC-0213

Voxzogo (vosoritide)

Revised

April 18, 2024

CC-0124

Keytruda (pembrolizumab)

Revised

April 18, 2024

*CC-0110

Perjeta (pertuzumab)

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-051291-24-CPN50531

PUBLICATIONS: April 2024 Provider Newsletter