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 Forms and Documents 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
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
About Us Newsroom Blog Member Forms COVID-19 Transparency in Coverage Find Care Rights & Responsibilities Policies & Best Practices Privacy Policy Website User Agreement Fraud & Abuse Technical Information Contact Us Locations Careers

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.

Information in other languages: Español   中文   Tiếng Việt   한국어   Français   العَرَبِيَّة   Hmoob   ру́сский   Tagalog   ગુજરાતી   ភាសាខ្មែរ   Deutsch   हिन्दी   ລາວ   日本語

© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.