Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialFebruary 1, 2024

Clinical Criteria updates for specialty pharmacy

Effective for dates of service on and after May 1, 2024, the following Clinical Criteria were developed and might result in services that were previously covered but may now be found to be not medically necessary.

For Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc., prior authorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of oncology will still require prior authorization by Carelon Medical Benefits Management, Inc., a separate company. This applies to members with PPO and HMO plans.

Clinical Criteria

Description

CC-0002

Colony stimulating factor agents

CC-0032

Botulinum toxin

CC-0041

Complement inhibitors

CC-0042

Monoclonal antibodies to interleukin-17

CC-0068

Growth hormone

CC-0133

Aliqopa (copanlisib)

CC-0195

Abecma (idecabtagene vicleucel

CC-0199

Empaveli (pegcetacoplan)

CC-0214

Carvykti (ciltacabtagene autoleucel)

CC-0226

Elahere (mirvetuximab)

CC-0252

Adzynma (ADAMTS13, recombinant-krhn)

CC-0254

Zilbysq (zilucoplan)

Access the Clinical Criteria document information.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

VABCBS-CM-048148-23

PUBLICATIONS: February 2024 Provider Newsletter