HealthKeepers, 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
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