Clinical Criteria In Pharmacy

Clinical Criteria

Anthem provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. The effective dates for using these documents for clinical reviews are communicated through the provider notification process.

Clinical criteria for orals or self-injectables can be found in our searchable drug lists within the Drug List Search.

Clinical Criteria for Commercial Plan Members

For Anthem commercial plan members using our Medical Specialty Precertification Drug List, precertification is required for certain medical specialty drugs.

 Medical Specialty Precertification Drug List

For commercial plan members using our Medical Specialty Drug Review program, requests for non-preferred specialty drugs may require additional clinical review under Anthem’s step therapy utilization management guidelines.

 Medical Step Therapy Drug List

With our Site of Care program, certain specialty drugs when covered under the medical benefit require additional clinical review under Anthem's clinical utilization management guidelines. Request for use of outpatient infusion or injectable therapy service in the hospital outpatient department or hospital outpatient clinic will be reviewed for medical necessity.

 Site of Care Drug List

Clinical criteria for orals or self-injectables can be found in our searchable drug lists.

After you have identified your list, enter the name of the drug you're looking for, select the drug and dose you want and click on Clinical Criteria under the Notes & Restrictions section.

Development of Clinical Criteria

All clinical criteria are developed to help guide clinically appropriate use of drugs and therapies and are reviewed and approved by the CarelonRx* Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is an independent and external committee including practicing physicians, pharmacists, and clinicians from leading academic medical centers and clinical practices with expertise in evidence-based medicine. All major clinical specialties are represented.

If you have questions or feedback, please contact druglist@carelon.com

Please note, you can perform a Clinical Criteria search by entering any of the information from the table into the search box.