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