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Physicians/Specialists
Facilities/Hospitals
Pharmacy
Publication Date: 
2022-06-22

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

https://www.bluecrossnc.com/providers/blue-medicare-providers/healthy-blue-medicare

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. All other marks are the property of their respective owners.

BNCCARE-0689-22 April 2022