Guideline UpdatesAnthem Blue Cross and Blue Shield | CommercialMay 1, 2025

Clinical Criteria updates for specialty pharmacy are available

Effective for dates of service on and after August 1, 2025, the following Clinical Criteria were developed and might result in previously covered services that may now be found not medically necessary.

For Anthem, the health plan will manage the prior authorization of these specialty pharmacy drugs. Drugs used to treat oncology will still require prior authorization by Carelon Medical Benefits Management, Inc. This applies to members with our preferred provider organization (PPO) and Anthem HealthKeepers (HMO).

Access the Clinical Criteria website here.

Document number

Clinical Criteria

CC‑0029

Dupixent (dupilumab)

CC‑0269

Nemluvio (nemolizumab‑ilto)

CC‑0122

Arzerra (ofatumumab)

CC‑0128

Atezolizumab (Tecentriq, Tecentriq Hybreza)

CC‑0158

Enhertu (fam‑trastuzumab deruxtecan‑nxki)

CC‑0121

Gazyva (obinutuzumab)

CC‑0061

Gonadotropin Releasing Hormone Analogs for the Treatment of Non‑Oncologic Indications

CC‑0125

Opdivo (nivolumab)

CC‑0008

Subcutaneous Hormonal Implants

CC‑0261

Winrevair (sotatercept‑csrk)

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-080576-25

PUBLICATIONS: May 2025 Provider Newsletter