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 May 20, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Blue Cross NC. 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. This notice is meant to inform the provider of new or revised criteria that has been adopted by Blue Cross NC only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date Document number Clinical Criteria title New or revised
December 30 2022 *ING-CC-0200 Aduhelm New
December 30 2022 *ING-CC-0215 Ketamine injection (Ketalar) New
December 30 2022 *ING-CC-0216 Opdualag (nivolumab and relatlimab-rmbw) New
December 30 2022 *ING-CC-0153 Adakveo (crizanlizumab) Revised
December 30 2022 *ING-CC-0002 Colony Stimulating Factor Agents Revised
December 30 2022 *ING-CC-0124 Keytruda (pembrolizumab) Revised
December 30 2022 ING-CC-0101 Torisel (temsirolimus) Revised
December 30 2022 *ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications Revised
December 30 2022 ING-CC-0143 Polivy (polatuzumab vedotin-piiq) Revised
December 30 2022 *ING-CC-0092 Adcetris (brentuximab vedotin) Revised
December 30 2022 ING-CC-0106 Erbitux (cetuximab) Revised
December 30 2022 *ING-CC-0175 Proleukin (aldesleukin) Revised
December 30 2022 ING-CC-0116 Bendamustine agents Revised
December 30 2022 *ING-CC-0145 Libtayo (cemiplimab-rwlc) Revised
December 30 2022 ING-CC-0151 Yescarta (axicabtagene ciloleucel) Revised
December 30 2022 *ING-CC-0032 Botulinum Toxin Revised
December 30 2022 *ING-CC-0052 Dihydroergotamine (DHE) injection Revised
December 30 2022 *ING-CC-0068 Growth Hormone Revised
December 30 2022 *ING-CC-0087 Gamifant (emapalumab) Revised
December 30 2022 ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection Revised
December 30 2022 ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease Revised
December 30 2022 *ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) Revised
December 30 2022 *ING-CC-0201 Rybrevant (amivantamab-ymjw) Revised
December 30 2022 *ING-CC-0119 Yervoy (ipilimumab) 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. All other marks are the property of their respective owners.
NCBCBS-CR-006367-22 September 2022