| Medical Guidelines |
Reason for Update |
| Aducanumab-avwa (Aduhelm™) |
Original medical policy criteria issued. Use of aducanumab-avwa is considered investigational for all indications including treatment of Alzheimer’s disease. |
| Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy |
Added HCPCS code C9075 to dosing reference table effective 7/1/2021, deleted C9399 termed 6/30/2021. |
| Belimumab (Benlysta®) |
Medical record documentation required for all indications. |
| CAR-T Therapy |
Added HCPCS code C9076 to dosing reference table effective 7/1/2021, deleted C9399 termed 6/30/2021. |
| Evinacumab-dgnb (Evkeeza™) |
Added HCPCS code C9079 to dosing reference table effective 7/1/2021, deleted C9399 termed 6/30/2021. |
| Infliximab (Remicade®) and Infliximab Biosimilars |
Changed requirement for trial and failure of preferred agents to include Avsola or Inflectra. |
| Lumasiran (Oxlumo™) |
Added HCPCS code J0224 to dosing reference table effective 7/1/2021, deleted C9074 and non-specific codes C9399, J3490, and J3590 termed 6/30/2021. |
| Rituximab for the Treatment of Rheumatoid Arthritis |
Added HCPCS code Q5123 to dosing reference table effective 7/1/2021, deleted non-specific codes C9399, J3490, and J3590 termed 6/30/2021. |
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