Publication Date: 

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).

On February 19, 2021, and March 4, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Healthy Blue + Medicare. 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
August 1, 2021 ING-CC-0186* Margenza (margetuximab-cmkb) New
August 1, 2021 ING-CC-0187* Breyanzi (lisocabtagene maraleucel) New
August 1, 2021 ING-CC-0188* Imcivree (setmelanotide) New
August 1, 2021 ING-CC-0189* Amondys 45 (casimersen) New
August 1, 2021 ING-CC-0190* Nulibry (fosdenopterin) New
August 1, 2021 ING-CC-0086* Spravato (esketamine) Nasal Spray Revised
August 1, 2021 ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki) Revised


Effective date Document number Clinical Criteria title New or revised
August 1, 2021 ING-CC-0167 Rituximab Agents for Oncologic Indications Step Therapy Revised
August 1, 2021 ING-CC-0157* Padcev (enfortumab vedotin) Revised
August 1, 2021 ING-CC-0125* Opdivo (nivolumab) Revised
August 1, 2021 ING-CC-0119* Yervoy (ipilimumab) Revised
August 1, 2021 ING-CC-0099 Abraxane (paclitaxel, protein bound) Revised
August 1, 2021 ING-CC-0094* Pemetrexed Agents (Alimta, Pemfexy) Revised
August 1, 2021 ING-CC-0123* Cyramza (ramucirumab) Revised
August 1, 2021 ING-CC-0115* Kadcyla (ado-trastuzumab) Revised
August 1, 2021 ING-CC-0033* Xolair (omalizumab) Revised
August 1, 2021 ING-CC-0043 Monoclonal Antibodies to Interleukin-5 Revised
August 1, 2021 ING-CC-0067* Prostacyclin Infusion and Inhalation Therapy Revised
August 1, 2021 ING-CC-0075* Rituximab Agents for Non-Oncologic Indications Revised
August 1, 2021 ING-CC-0034* Hereditary Angioedema Agents Revised
August 1, 2021 ING-CC-0028* Benlysta (belimumab) Revised