Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2021-07-26

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 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, 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.

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

 

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.
BNCCARE-0172-21 July 2021 519248MUPENMUB