Skip to main content
Shop Plans Learn more about our coverage options including health, Medicare, dental and vision options for you, your family or your employees. Get Started Individual & Family Medicare Employer Vision Dental International Travel Find Care FAQ Blog Members Stay on top of your health care with helpful member resources. Members Home Medicare Health Dental Vision Find Care Member Knowledge Center Member Forms Medicare Forms Library Make a Payment Federal Employees Student Blue Healthy Blue Providers Access tools, policies and the latest information to help you care for our members. Providers Home Network Participation Networks & Programs Claims, Appeals & Inquiries Prior Authorization Services & CPT codes Prescription Drug Search Policies, Guidelines & Codes Provider News Provider FAQ Contact Us Employers Learn about our coverage options for small and large employers, and access tools and resources for your group. Employers Home Shop Employer Plans Employer Portal Support Member Forms & Resources Find Care Blog Agents Access the tools you need: rate quotes, applications, forms, the latest industry news, marketing materials and more. Agents Home Agent Services Check Eligibility Find Care Member Forms & Resources Medicare Forms Library
Contact Us
Log In
I am ... Please select A member A provider An employer An agent
Log in to Agent Services
Log in to Employer Services Register for Employer Services I'm registered but need portal access
Username Forgot username? Continue to Log In Register for Blue Connect Need help? Learn how to log in.
Log in to Blue e Register for Blue e Log in to Dental Blue
Back
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