Guideline UpdatesHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsAugust 21, 2023

Clinical Criteria updates - May 2023

Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.

On August 19, 2022, September 15, 2022, November 18, 2022, December 22, 2022, May 2, 2023, and May 19, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for HealthKeepers, Inc. These policies were developed, revised, or reviewed to support clinical coding edits. 

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: Newly published criteria.
  • Revised: Addition or removal of medical necessity requirements, new document number
  • Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

Please share this notice with other providers in your practice and office staff.

Please note: 

  • The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by HealthKeepers, Inc. only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date

Clinical Criteria  number

Clinical Criteria title

New or revised

September 22, 2023

*CC-0237

Qalsody (tofersen) 

New

September 22, 2023

*CC-0238

Hydroxyprogesterone caproate 

New

September 22, 2023

*CC-0240

Zynyz (retifanlimab-dlwr) 

New

September 22, 2023

CC-0165

Trodelvy (sacituzumab govitecan)

Revised

September 22, 2023

CC-0002

Colony Stimulating Factor Agents

Revised

September 22, 2023

CC-0128

Tecentriq (atezolizumab)

Revised

September 22, 2023

CC-0098

Doxorubicin Liposome (Doxil, Lipodox)

Revised

September 22, 2023

CC-0101

Torisel (temsirolimus)

Revised

September 22, 2023

CC-0107

Bevacizumab for Non-Ophthalmologic Indications

Revised

September 22, 2023

CC-0143

Polivy (polatuzumab vedotin-piiq)

Revised

September 22, 2023

CC-0092

Adcetris (brentuximab vedotin)

Revised

September 22, 2023

CC-0095

Velcade (bortezomib)

Revised

September 22, 2023

CC-0105

Vectibix (panitumumab)

Revised

September 22, 2023

CC-0178

Synribo (omacetaxine mepesuccinate)

Revised

September 22, 2023

CC-0114

Jevtana (cabazitaxel)

Revised

September 22, 2023

CC-0145

Libtayo (cemiplimab-rwlc)

Revised

September 22, 2023

*CC-0032

Botulinum Toxin

Revised

September 22, 2023

CC-0068

Growth Hormone

Revised

September 22, 2023

*CC-0057

Krystexxa (pegloticase)

Revised

September 22, 2023

*CC-0125

Opdivo (nivolumab) 

Revised

September 22, 2023

*CC-0225

Tzield (teplizumab-mzwv)

Revised

September 22, 2023

*CC-0167

Rituximab Agents for Oncologic Indications

Revised

September 22, 2023

*CC-0075

Rituximab Agents for Non-Oncologic Indications 

Revised

September 22, 2023

*CC-0182

Iron Agents 

Revised

September 22, 2023

*CC-0124

Keytruda (pembrolizumab)

Revised

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.

VABCBS-CD-031932-23-CPN30759

PUBLICATIONS: September 2023 Provider Newsletter