Medical Drug Benefit Clinical Criteria Updates
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 November 19, 2021, January 4, 2022, and February 25, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Blue Cross and Blue Shield of North Carolina. 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 |
|---|---|---|---|
| July 23, 2022 | *ING-CC-0211 | Kimmtrak (tebentafusp-tebn) | New |
| July 23, 2022 | *ING-CC-0210 | Enjaymo (sutimlimab-jome) | New |
| July 23, 2022 | *ING-CC-0213 | Voxzogo (vosoritide) | New |
| July 23, 2022 | *ING-CC-0212 | Tezspire (tezepelumab-ekko) | New |
| July 23, 2022 | *ING-CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
| July 23, 2022 | ING-CC-0157 | Padcev (enfortumab vedotin) | Revised |
| July 23, 2022 | ING-CC-0125 | Opdivo (nivolumab) | Revised |
| July 23, 2022 | ING-CC-0119 | Yervoy (ipilimumab) | Revised |
| July 23, 2022 | *ING-CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
| July 23, 2022 | ING-CC-0120 | Kyprolis (carfilzomib) | Revised |
| July 23, 2022 | ING-CC-0126 | Blincyto (blinatumomab) | Revised |
| July 23, 2022 | ING-CC-0129 | Bavencio (avelumab) | Revised |
| July 23, 2022 | *ING-CC-0090 | Ixempra (ixabepilone) | Revised |
| July 23, 2022 | ING-CC-0110 | Perjeta (pertuzumab) | Revised |
| July 23, 2022 | ING-CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
| July 23, 2022 | ING-CC-0108 | Halaven (eribulin) | Revised |
| July 23, 2022 | *ING-CC-0033 | Xolair (omalizumab) | Revised |
| July 23, 2022 | *ING-CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised |
| July 23, 2022 | ING-CC-0038 | Human Parathyroid Hormone Agents | Revised |
| July 23, 2022 | *ING-CC-0186 | Margenza (margetuximab-cmkb) | Revised |
| July 23, 2022 | *ING-CC-0124 | Keytruda (pembrolizumab) | Revised |
| July 23, 2022 | *ING-CC-0078 | Orencia (abatacept) | Revised |
| July 23, 2022 | ING-CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
| July 23, 2022 | ING-CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
| July 23, 2022 | *ING-CC-0029 | Dupixent (dupilumab) | Revised |
| July 23, 2022 | *ING-CC-0208 | Adbry (tralokinumab) | Revised |
| July 23, 2022 | *ING-CC-0209 | Leqvio (inclisiran) | Revised |
| July 23, 2022 | *ING-CC-0166 | Trastuzumab Agents | Revised |
| July 23, 2022 | *ING-CC-0107 | Bevacizumab for Non-ophthalmologic Indications | Revised |
For more information, visit Healthy Blue + Medicare.
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