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