Clinical Criteria updates for specialty pharmacy are available

Effective for dates of service on and after November 1, 2022, the following Clinical Criteria were revised 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 our 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 AIM Specialty Health_®* (AIM).  This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Access the Clinical Criteria document information.

 

ING-CC-0068	Growth Hormone
ING-CC-0087	Gamifant (emapalumab)
ING-CC-0107	Bevacizumab for Non-Ophthalmologic Indications
ING-CC-0118	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)
ING-CC-0119	Yervoy (ipilimumab)
ING-CC-0124	Keytruda (pembrolizumab)
ING-CC-0153	Adakveo (crizanlizumab)
ING-CC-0215	Ketamine injection (Ketalar)
ING-CC-0216	Opdualag (nivolumab and relatlimab-rmbw)

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc.

 

VABCBS-CM-002885-22