HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJune 12, 2023
Clinical Criteria Updates for February 2023
Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
Summary: On May 20, 2022, August 19, 2022, September 12, 2022, September 15, 2022, November 18, 2022, December 12, 2022, and February 24, 2023, 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 HealthKeepers, Inc. has adopted. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Document number | Clinical Criteria title | New or revised |
July 14, 2023 | *CC-0232 | Lunsumio (mosunetuzumab-axgb) | New |
July 14, 2023 | *CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | New |
July 14, 2023 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | New |
July 14, 2023 | *CC-0234 | Syfovre (pegcetacoplan) | New |
July 14, 2023 | *CC-0231 | Lamzede (velmanase alfa-tycv) | New |
July 14, 2023 | CC-0007 | Synagis (palivizumab) | Revised |
July 14, 2023 | CC-0210 | Enjaymo (sutimlimab-jome) | Revised |
July 14, 2023 | *CC-0128 | Tecentriq (atezolizumab) | Revised |
July 14, 2023 | *CC-0116 | Bendamustine agents | Revised |
July 14, 2023 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
July 14, 2023 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
July 14, 2023 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
July 14, 2023 | *CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
July 14, 2023 | CC-0125 | Opdivo (nivolumab) | Revised |
July 14, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised |
July 14, 2023 | CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
July 14, 2023 | *CC-0093 | Docetaxel (Taxotere) | Revised |
July 14, 2023 | CC-0094 | Pemetrexed Agents (Alimta, Pemfexy) | Revised |
July 14, 2023 | CC-0130 | Imfinzi (durvalumab) | Revised |
July 14, 2023 | CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
July 14, 2023 | CC-0123 | Cyramza (ramucirumab) | Revised |
July 14, 2023 | CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
July 14, 2023 | CC-0121 | Gazyva (obinutuzumab) | Revised |
July 14, 2023 | *CC-0096 | Asparagine Specific Enzymes | Revised |
July 14, 2023 | *CC-0120 | Kyprolis (carfilzomib) | Revised |
July 14, 2023 | CC-0117 | Empliciti (elotuzumab) | Revised |
July 14, 2023 | CC-0126 | Blincyto (blinatumomab) | Revised |
July 14, 2023 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
July 14, 2023 | CC-0097 | Vidaza (azacitidine) | Revised |
July 14, 2023 | CC-0129 | Bavencio (avelumab) | Revised |
July 14, 2023 | CC-0090 | Ixempra (ixabepilone) | Revised |
July 14, 2023 | *CC-0110 | Perjeta (pertuzumab) | Revised |
July 14, 2023 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
July 14, 2023 | CC-0124 | Keytruda (pembrolizumab) | Revised |
July 14, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
July 14, 2023 | *CC-0160 | Vyepti (eptinezumab) | Revised |
July 14, 2023 | *CC-0020 | Tysabri (natalizumab) | Revised |
July 14, 2023 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
July 14, 2023 | *CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
July 14, 2023 | *CC-0001 | Erythropoiesis Stimulating Agents | Revised |
July 14, 2023 | *CC-0166 | Trastuzumab Agents | Revised |
July 14, 2023 | *CC-0075 | Rituximab agents for Non-Oncologic Indications | Revised |
July 14, 2023 | *CC-0167 | Rituximab Agents for Oncologic Indications | Revised |
July 14, 2023 | *CC-0182 | Iron Agents | Revised |
July 14, 2023 | *CC-0107 | Bevacizumab for Non-ophthalmologic Indications | Revised |
July 14, 2023 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.
VABCBS-CD-024312-23-CPN24009
PUBLICATIONS: July 2023 Provider Newsletter
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