Clinical Criteria updates for specialty pharmacy are available

Effective for dates of service on and after June 1, 2023, 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), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH) plans.

 

Access the Clinical Criteria document information.

 

CC-0029	Dupixent (dupilumab)
CC-0228	Leqembi (lecanemab)

* Carelon Medical Benefits Management, Inc. is an independent company providing some utilization review services on behalf of the health plan.
VABCBS-CM-018143-23