Clinical Criteria Updates Notification June 2021
Please note, this communication applies to Healthy Blue + Medicare℠ (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 |
For more information, visit Healthy Blue + Medicare
BNCCARE-0200-21 September 2021
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2024 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.