HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsApril 24, 2024
Clinical Criteria updates — November 2023
Summary
On February 24, 2023, and November 17, 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 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 |
May 26, 2024 | *CC-0252 | Adzynma (ADAMTS13, recombinant-krhn) | New |
May 26, 2024 | *CC-0253 | Aphexda (motixafortide) | New |
May 26, 2024 | *CC-0254 | Zilbysq (zilucoplan) | New |
May 26, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised |
May 26, 2024 | CC-0223 | Imjudo (tremelimumab-actl) | Revised |
May 26, 2024 | *CC-0059 | Selected Injectable NK-1 Antiemetic Agents | Revised |
May 26, 2024 | CC-0074 | Akynzeo (fosnetupitant and palonosetron) for injection | Revised |
May 26, 2024 | *CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
May 26, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
May 26, 2024 | CC-0150 | Kymriah (tisagenlecleucel) | Revised |
May 26, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
May 26, 2024 | CC-0133 | Aliqopa (copanlisib) | Revised |
May 26, 2024 | CC-0205 | Fyarro (sirolimus albumin bound) | Revised |
May 26, 2024 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
May 26, 2024 | *CC-0226 | Elahere (mirvetuximab) | Revised |
May 26, 2024 | CC-0125 | Opdivo (nivolumab) | Revised |
May 26, 2024 | CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | Revised |
May 26, 2024 | *CC-0009 | Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis | Revised |
May 26, 2024 | *CC-0014 | Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis |
Revised |
May 26, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
May 26, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised |
May 26, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised |
May 26, 2024 | *CC-0032 | Botulinum Toxin | Revised |
May 26, 2024 | *CC-0068 | Growth Hormone | Revised |
May 26, 2024 | *CC-0173 | Enspryng (satralizumab-mwge) | Revised |
May 26, 2024 | *CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
May 26, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised |
May 26, 2024 | *CC-0041 | Complement Inhibitors | Revised |
May 26, 2024 | *CC-0071 | Entyvio (vedolizumab) | Revised |
May 26, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised |
May 26, 2024 | *CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
May 26, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
May 26, 2024 | *CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
May 26, 2024 | *CC-0078 | Orencia (abatacept) | Revised |
May 26, 2024 | *CC-0063 | Ustekinumab Agents | Revised |
May 26, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
May 26, 2024 | CC-0003 | Immunoglobulins | Revised |
May 26, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
May 26, 2024 | CC-0247 | Beyfortus (nirsevimab) | Revised |
May 26, 2024 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
May 26, 2024 | CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
May 26, 2024 | CC-0209 | Leqvio (inclisiran) | Revised |
May 26, 2024 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
HealthKeepers, Inc. is an independent licensee of the Blue Cross Blue Shield Association. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
VABCBS-CD-050630-24-CPN49889
PUBLICATIONS: May 2024 Provider Newsletter
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