State & FederalMedicare AdvantageApril 1, 2022

Clinical Criteria updates

On November 19, 2021, December 13, 2021, and January 10, 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. For 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 members of 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.

 

Effective date

Document number

Clinical Criteria Title

New or revised

04/08/2022

*ING-CC-0205

Fyarro (sirolimus albumin bound)

New

04/08/2022

*ING-CC-0206

Besremi (ropeginterferon alfa-2b-njft)

New

04/08/2022

*ING-CC-0207

Vyvgart (efgartigimod alfa-fcab)

New

04/08/2022

*ING-CC-0208

Adbry (tralokinumab)

New

04/08/2022

*ING-CC-0209

Leqvio (inclisiran)

New

04/08/2022

ING-CC-0124

Keytruda (pembrolizumab)

Revised

04/08/2022

ING-CC-0079

Strensiq (Asfotase Alfa)

Revised

04/08/2022

ING-CC-0015

Infertility and HCG Agents

Revised

04/08/2022

ING-CC-0102

Gonadotropin releasing hormone (GNRH)  Analogs for Oncologic Indications

Revised

04/08/2022

ING-CC-0168

Tecartus (brexucabtagene autoleucel)

Revised

04/08/2022

ING-CC-0029

Dupixent (dupilumab)

Revised

04/08/2022

*ING-CC-0004

Repository Corticotropin Injection

Revised

04/08/2022

ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Revised

 

ABSCRNU-0315-22

PUBLICATIONS: April 2022 Anthem Provider News - Wisconsin