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Clinical Criteria Updates Notification August 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 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 DATE | DOCUMENT NUMBER | CLINICAL CRITERIA TITLE | NEW OR REVISED |
|---|---|---|---|
| January 10, 2022 | ING-CC-0202* | Saphnelo (anifrolumab-fnia) | New |
| January 10, 2022 | ING-CC-0203* | Ryplazim (plasminogen, human-tvmh) | New |
| January 10, 2022 | ING-CC-0010* | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised |
| January 10, 2022 | ING-CC00034* | Hereditary Angioedema Agents | Revised |
| January 10, 2022 | ING-CC-0027* | Denosumab Agents | Revised |
| January 10, 2022 | ING-CC-0001* | Erythropoiesis Stimulating Agents | Revised |
| January 10, 2022 | ING-CC-0156* | Reblozyl (luspatercept) | Revised |
| January 10, 2022 | ING-CC-0124 | Keytruda (pembrolizumab) | Revised |
| January 10, 2022 | ING-CC-0104* | Levoleucovorin Agents | Revised |
| January 10, 2022 | ING-CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
| January 10, 2022 | ING-CC-0009* | Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis | Revised |
| January 10, 2022 | ING-CC-0020 | Tysabri (natalizumab) | Revised |
| January 10, 2022 | ING-CC-0029* | Dupixent (dupilumab) | Revised |
| January 10, 2022 | ING-CC-0038 | Human Parathyroid Hormone Agents | Revised |
| January 10, 2022 | ING-CC-0182* | Iron Agents | Revised |
| January 10, 2022 | ING-CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised |
| January 10, 2022 | ING-CC-0096 | Asparagine Specific Enzymes | Revised |
| January 10, 2022 | ING-CC-0169 | Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf) | Revised |
| January 10, 2022 | ING-CC-0193 | Evkeeza (evinacumab) | Revised |
| January 10, 2022 | ING-CC-0081* | Crysvita (burosumab-twza) | Revised |
For more information, visit Healthy Blue + Medicare
BNCCARE-0219-21 October 2021
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