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Clinical Criteria Updates Notification August 2021 October 19, 2021 Ancillary Pharmacy Medical Policy & Clinical Guidelines

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 20, 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 DATEDOCUMENT NUMBERCLINICAL CRITERIA TITLENEW OR REVISED
January 10, 2022ING-CC-0202*Saphnelo (anifrolumab-fnia)New
January 10, 2022ING-CC-0203*Ryplazim (plasminogen, human-tvmh)New
January 10, 2022ING-CC-0010*Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) InhibitorsRevised
January 10, 2022ING-CC00034*Hereditary Angioedema AgentsRevised
January 10, 2022ING-CC-0027*Denosumab AgentsRevised
January 10, 2022ING-CC-0001*Erythropoiesis Stimulating AgentsRevised
January 10, 2022ING-CC-0156*Reblozyl (luspatercept)Revised
January 10, 2022ING-CC-0124Keytruda (pembrolizumab)Revised
January 10, 2022ING-CC-0104*Levoleucovorin AgentsRevised
January 10, 2022ING-CC-0062Tumor Necrosis Factor AntagonistsRevised
January 10, 2022ING-CC-0009*Lemtrada (alemtuzumab) for the Treatment of Multiple SclerosisRevised
January 10, 2022ING-CC-0020Tysabri (natalizumab)Revised
January 10, 2022ING-CC-0029*Dupixent (dupilumab)Revised
January 10, 2022ING-CC-0038Human Parathyroid Hormone AgentsRevised
January 10, 2022ING-CC-0182*Iron AgentsRevised
January 10, 2022ING-CC-0075Rituximab Agents for Non-Oncologic IndicationsRevised
January 10, 2022ING-CC-0096Asparagine Specific EnzymesRevised
January 10, 2022ING-CC-0169Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)Revised
January 10, 2022ING-CC-0193Evkeeza (evinacumab)Revised
January 10, 2022ING-CC-0081*Crysvita (burosumab-twza)Revised

For more information, visit Healthy Blue + Medicare

BNCCARE-0219-21 October 2021