Medical Policy Updates

Blue Cross NC Pharmacy/Drug Medical Policy Update For July 1, 2021

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.