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Clinical Criteria Updates Notification - February 2021 May 17, 2021 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 February 19, 2021, and March 4, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Healthy Blue + Medicare. 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, email druglist@ingenio-rx.com.

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
August 1, 2021ING-CC-0186*Margenza (margetuximab-cmkb)New
August 1, 2021ING-CC-0187*Breyanzi (lisocabtagene maraleucel)New
August 1, 2021ING-CC-0188*Imcivree (setmelanotide)New
August 1, 2021ING-CC-0189*Amondys 45 (casimersen)New
August 1, 2021ING-CC-0190*Nulibry (fosdenopterin)New
August 1, 2021ING-CC-0086*Spravato (esketamine) Nasal SprayRevised
August 1, 2021ING-CC-0158Enhertu (fam-trastuzumab deruxtecan-nxki)Revised
EFFECTIVE DATEDOCUMENT NUMBERCLINICAL CRITERIA TITLENEW OR REVISED
August 1, 2021ING-CC-0167Rituximab Agents for Oncologic Indications Step TherapyRevised
August 1, 2021ING-CC-0157*Padcev (enfortumab vedotin)Revised
August 1, 2021ING-CC-0125*Opdivo (nivolumab)Revised
August 1, 2021ING-CC-0119*Yervoy (ipilimumab)Revised
August 1, 2021ING-CC-0099Abraxane (paclitaxel, protein bound)Revised
August 1, 2021ING-CC-0094*Pemetrexed Agents (Alimta, Pemfexy)Revised
August 1, 2021ING-CC-0123*Cyramza (ramucirumab)Revised
August 1, 2021ING-CC-0115*Kadcyla (ado-trastuzumab)Revised
August 1, 2021ING-CC-0033*Xolair (omalizumab)Revised
August 1, 2021ING-CC-0043Monoclonal Antibodies to Interleukin-5Revised
August 1, 2021ING-CC-0067*Prostacyclin Infusion and Inhalation TherapyRevised
August 1, 2021ING-CC-0075*Rituximab Agents for Non-Oncologic IndicationsRevised
August 1, 2021ING-CC-0034*Hereditary Angioedema AgentsRevised
August 1, 2021ING-CC-0028*Benlysta (belimumab)Revised
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