On November 19, 2021, January 4, 2022, and February 25, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 would like 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 members of your practice and office staff.

 

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.

 

Effective date

Document number

Clinical Criteria title

New or revised

06/09/2022

*ING-CC-0211

Kimmtrak (tebentafusp-tebn)

New

06/09/2022

*ING-CC-0210

Enjaymo (sutimlimab-jome)

New

06/09/2022

*ING-CC-0213

Voxzogo (vosoritide)

New

06/09/2022

*ING-CC-0212

Tezspire (tezepelumab-ekko)

New

06/09/2022

*ING-CC-0086

Spravato (esketamine) Nasal Spray

Revised

06/09/2022

ING-CC-0157

Padcev (enfortumab vedotin)

Revised

06/09/2022

ING-CC-0125

Opdivo (nivolumab)

Revised

06/09/2022

ING-CC-0119

Yervoy (ipilimumab)

Revised

06/09/2022

*ING-CC-0099

Abraxane (paclitaxel, protein bound)

Revised

06/09/2022

ING-CC-0120

Kyprolis (carfilzomib)

Revised

06/09/2022

ING-CC-0126

Blincyto (blinatumomab)

Revised

06/09/2022

ING-CC-0129

Bavencio (avelumab)

Revised

06/09/2022

*ING-CC-0090

Ixempra (ixabepilone)

Revised

06/09/2022

ING-CC-0110

Perjeta (pertuzumab)

Revised

06/09/2022

ING-CC-0115

Kadcyla (ado-trastuzumab)

Revised

06/09/2022

ING-CC-0108

Halaven (eribulin)

Revised

06/09/2022

*ING-CC-0033

Xolair (omalizumab)

Revised

06/09/2022

*ING-CC-0043

Monoclonal Antibodies to Interleukin-5

Revised

06/09/2022

ING-CC-0038

Human Parathyroid Hormone Agents

Revised

06/09/2022

*ING-CC-0186

Margenza (margetuximab-cmkb)

Revised

06/09/2022

*ING-CC-0124

Keytruda (pembrolizumab)

Revised

06/09/2022

*ING-CC-0078

Orencia (abatacept)

Revised

06/09/2022

ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

06/09/2022

ING-CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

06/09/2022

*ING-CC-0029

Dupixent (dupilumab)

Revised

06/09/2022

*ING-CC-0208

Adbry (tralokinumab)

Revised

06/09/2022

*ING-CC-0209

Leqvio (inclisiran)

Revised

06/09/2022

*ING-CC-0166

Trastuzumab Agents

Revised

06/09/2022

*ING-CC-0107

Bevacizumab for Non-ophthalmologic Indications

Revised

 

AWI-NU-0376-22



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June 2022 Anthem Provider News - Wisconsin