Clinical Criteria Updates for Healthy Blue + MedicareSM (HMO D-SNP)
Oct. 6, 2022 Update: This communication has been updated to include effective dates.
Please note, this communication applies to Healthy Blue + MedicareSM(HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Summary: On September 22, 2021, and November 19, 2021, the Pharmacy and Therapeutics (P&T) committee approved the following Clinical Criteria applicable to the medical drug benefit for Blue Cross NC. 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.
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
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 |
|---|---|---|---|
| April 29, 2022 | *ING-CC-0204 | Tivdak (tisotumab vedotin-tftv) | New |
| April 29, 2022 | *ING-CC-0018 | Lumizyme (alglucosidase alfa); Nexviazyme (avalglucosidase alfa-ngpf) | Revised |
| April 29, 2022 | *ING-CC-0128 | Tecentriq (atezolizumab) | Revised |
| April 29, 2022 | *ING-CC-0012 | Brineura (cerliponase alfa) | Revised |
| April 29, 2022 | *ING-CC-0021 | Fabrazyme (agalsidase beta) | Revised |
| April 29, 2022 | *ING-CC-0017 | Xiaflex (collagenase clostridium histolyticum) | Revised |
| April 29, 2022 | *ING-CC-0026 | Testosterone Injectable | Revised |
| April 29, 2022 | *ING-CC-0100 | Istodax (romidepsin) | Revised |
| April 29, 2022 | *ING-CC-0125 | Opdivo (nivolumab) | Revised |
| April 29, 2022 | ING-CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
| April 29, 2022 | ING-CC-0124 | Keytruda (pembrolizumab) | Revised |
| April 29, 2022 | *ING-CC-0061 | GnRH Analogs for the Treatment of Non-Oncologic Indications | Revised |
| April 29, 2022 | *ING-CC-0148 | Agents for Hemophilia B | Revised |
| April 29, 2022 | *ING-CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised |
| April 29, 2022 | *ING-CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
| April 29, 2022 | ING-CC-0168 | Tecartus (brexucabtagene autoleucel) | Revised |
| April 29, 2022 | *ING-CC-0195 | Abecma (idecabtagene vicleucel) | Revised |
| April 29, 2022 | *ING-CC-0001 | Erythropoiesis Stimulating Agents | Revised |
| April 29, 2022 | *ING-CC-0173 | Enspryng (satralizumab-mwge) | Revised |
| April 29, 2022 | *ING-CC-0170 | Uplizna (inebilizumab-cdon) | Revised |
| April 29, 2022 | *ING-CC-0041 | Complement Inhibitors | Revised |
| April 29, 2022 | *ING-CC-0071 | Entyvio (vedolizumab) | Revised |
| April 29, 2022 | *ING-CC-0064 | Interleukin-1 Inhibitors | Revised |
| April 29, 2022 | *ING-CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
| April 29, 2022 | *ING-CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
| April 29, 2022 | *ING-CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
| April 29, 2022 | *ING-CC-0078 | Orencia (abatacept) | Revised |
| April 29, 2022 | *ING-CC-0063 | Stelara (ustekinumab) | Revised |
| April 29, 2022 | *ING-CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
| April 29, 2022 | ING-CC-0003 | Immunoglobulins | Revised |
| April 29, 2022 | *ING-CC-0049 | Radicava (edaravone) | Revised |
| April 29, 2022 | *ING-CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised |
| April 29, 2022 | *ING-CC-0072 | Selective Vascular Endothelial Growth Factor (VEGF) Antagonists | Revised |
| April 29, 2022 | ING-CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
| April 29, 2022 | ING-CC-0106 | Erbitux (cetuximab) | Revised |
| April 29, 2022 | ING-CC-0105 | Vectibix (panitumumab) | Revised |
| April 29, 2022 | ING-CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
| April 29, 2022 | *ING-CC-0068 | Growth Hormone | Revised |
For more information, visit Healthy Blue + Medicare
BNCCARE-0259-22 January 2022
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