Publication Date: 

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina.

Summary: On August 21, 2020, November 20, 2020, and June 24, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Insert plan. 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.

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
December 20, 2021 *ING-CC-0201 Rybrevant (amivantamab-vmjm) New
December 20, 2021 *ING-CC-0042 Monoclonal Antibodies to Interleukin-17 Revised
December 20, 2021 *ING-CC-0050 Monoclonal Antibodies to Interleukin-23 Revised
December 20, 2021 ING-CC-0125 Opdivo (nivolumab) Revised
December 20, 2021 ING-CC-0124 Keytruda (pembrolizumab) Revised
December 20, 2021 *ING-CC-0102 GnRH Analogs for Oncologic Indications Revised
December 20, 2021 ING-CC-0076 Nulojix (belatacept) Revised
December 20, 2021 *ING-CC-0077 Palynziq (pegvaliase-pqpz) Revised
December 20, 2021 ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy Revised
December 20, 2021 ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection Revised
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is an independent licensee of the Blue Cross and Blue Shield Association.
BNCCARE-0200-21 September 2021