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

Clinical Criteria updates for specialty pharmacy are available

Effective on and after August 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 Preferred Provider Organization (PPO), and Anthem HealthKeepers (HMO).

Access the Clinical Criteria document information.

CC-0033

Xolair (omalizumab)

CC-0088

Elzonris (tagraxofusp-erzs)

CC-0090

Ixempra (ixabepilone)

CC-0096

Asparagine Specific Enzymes

CC-0099

Abraxane (paclitaxel, protein bound)

CC-0112

Xofigo (Radium Ra 223 Dichloride)

CC-0115

Kadcyla (ado-trastuzumab)

CC-0123

Cyramza (ramucirumab)

CC-0125

Opdivo (nivolumab)

CC-0126

Blincyto (blinatumomab)

CC-0131

Besponsa (inotuzumab ozogamicin)

CC-0230

Adstiladrin (nadofaragene firadenovec-vncg)

CC-0258

iDose TR (travoprost implant)

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.

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PUBLICATIONS: May 2024 Provider Newsletter