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Medicare Advantage - Clinical Criteria Updates Notification March 2021 June 03, 2021 Pharmacy Claims & Coding 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 March 25, 2021, and April 8, 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, 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 30, 2021ING-CC-0195*Abecma (idecabtagene vicleucel)New
August 30, 2021ING-CC-0191*Pepaxto (melphalan flufenamide; melflufen)New
August 30, 2021ING-CC-0192*Cosela (trilaciclib)New
August 30, 2021ING-CC-0193*Evkeeza (evinacumab)New
August 30, 2021ING-CC-0194*Cabenuva (cabotegravir extended-release; rilpivirine extended-release) InjectionNew
August 30, 2021ING-CC-0125Opdivo (nivolumab)Revised
August 30, 2021ING-CC-0064Interleukin-1 InhibitorsRevised
August 30, 2021ING-CC-0159*Scenesse (afamelanotide)Revised
August 30, 2021ING-CC-0151Yescarta (axicabtagene ciloleucel)Revised
August 30, 2021ING-CC-0145*Libtayo (cemiplimab-rwlc)Revised
August 30, 2021ING-CC-0130*Imfinzi (durvalumab)Revised
August 30, 2021ING-CC-0127Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)Revised
August 30, 2021ING-CC-0075*Rituximab Agents for Non-Oncologic IndicationsRevised

For more information, visit our Providers page.

BNCCARE-0139-21 May 2021                              518931MUPENMUB

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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