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 March 25, 2021, and April 8, 2021, 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.

Effective date Document number Clinical Criteria title New or revised
August 30, 2021 ING-CC-0195* Abecma (idecabtagene vicleucel) New
August 30, 2021 ING-CC-0191* Pepaxto (melphalan flufenamide; melflufen) New
August 30, 2021 ING-CC-0192* Cosela (trilaciclib) New
August 30, 2021 ING-CC-0193* Evkeeza (evinacumab) New
August 30, 2021 ING-CC-0194* Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection New
August 30, 2021 ING-CC-0125 Opdivo (nivolumab) Revised
August 30, 2021 ING-CC-0064 Interleukin-1 Inhibitors Revised
August 30, 2021 ING-CC-0159* Scenesse (afamelanotide) Revised
August 30, 2021 ING-CC-0151 Yescarta (axicabtagene ciloleucel) Revised
August 30, 2021 ING-CC-0145* Libtayo (cemiplimab-rwlc) Revised
August 30, 2021 ING-CC-0130* Imfinzi (durvalumab) Revised
August 30, 2021 ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) Revised
August 30, 2021 ING-CC-0075* Rituximab Agents for Non-Oncologic Indications 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-0139-21 May 2021                              518931MUPENMUB