Medicare Advantage - Medical Drug Benefit Clinical Criteria Updates May 2021
Please note, this communication applies to Healthy Blue + Medicare℠ (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
On August 21, 2020 and May 21, 2021, the Pharmacy and Therapeutic (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. For questions or additional information, email druglist@ingenio-rx.com.
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.
Please 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 |
|---|---|---|---|
| October 19, 2021 | *ING-CC-0196 | Zynlonta (loncastuximab tesirine-lpyl) | New |
| October 19, 2021 | *ING-CC-0197 | Jemperli (dostarlimab) | New |
| October 19, 2021 | *ING-CC-0198 | Relizorb (immobilized lipase) cartridge | New |
| October 19, 2021 | *ING-CC-0199 | Empaveli (pegcetacoplan) | New |
| October 19, 2021 | ING-CC-0163ING-CC-0163 | Durysta (bimatoprost implant) | Revised |
| October 19, 2021 | *ING-CC-0111 | Nplate (romiplostim) | Revised |
| October 19, 2021 | *ING-CC-0137 | Cablivi (caplacizumab-yhdp) | Revised |
| October 19, 2021 | ING-CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
| October 19, 2021 | *ING-CC-0124 | Keytruda (pembrolizumab) | Revised |
| October 19, 2021 | *ING-CC-0128 | Tecentriq (atezolizumab) | Revised |
| October 19, 2021 | ING-CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
| October 19, 2021 | ING-CC-0098 | Doxorubicin Liposome (Doxil, Lipodox) | Revised |
| October 19, 2021 | *ING-CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
| October 19, 2021 | ING-CC-0127 | Darzalex (daratumumab) | Revised |
| October 19, 2021 | ING-CC-0142 | Somatuline Depot (lanreotide) | Revised |
| October 19, 2021 | *ING-CC-0114 | Jevtana (cabazitaxel) | Revised |
| October 19, 2021 | ING-CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
| October 19, 2021 | ING-CC-0120 | Kyprolis (carfilzomib) | Revised |
| October 19, 2021 | *ING-CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
| October 19, 2021 | ING-CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised |
| October 19, 2021 | ING-CC-0150 | Kymriah (tisagenlecleucel) | Revised |
| October 19, 2021 | ING-CC-0125 | Opdivo (nivolumab) | Revised |
| October 19, 2021 | *ING-CC-0032 | Botulinum Toxin | Revised |
| October 19, 2021 | *ING-CC-0160 | Vyepti (eptinezumab) | Revised |
| October 19, 2021 | *ING-CC-0052 | Dihydroergotamine (DHE) injection | Revised |
| October 19, 2021 | *ING-CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
| October 19, 2021 | ING-CC-0064 | Interleukin-1 inhibitors | Revised |
| October 19, 2021 | *ING-CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
| October 19, 2021 | *ING-CC-0102 | GNRH Analogs for Oncologic Indications | Revised |
| October 19, 2021 | *ING-CC-0020 | Tysabri (natalizumab) | Revised |
For more information, visit Healthy Blue + Medicare.
BNCCARE-0172-21 July 2021 519248MUPENMUB
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