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Medicare Advantage - Medical Drug Benefit Clinical Criteria Updates May 2021 July 26, 2021 Claims & Coding Medical Policy & Clinical Guidelines Blue Medicare

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 August 21, 2020 and May 21, 2021, the Pharmacy and Therapeutic (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. For questions or 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.

Please 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
October 19, 2021*ING-CC-0196Zynlonta (loncastuximab tesirine-lpyl)New
October 19, 2021*ING-CC-0197Jemperli (dostarlimab)New
October 19, 2021*ING-CC-0198Relizorb (immobilized lipase) cartridgeNew
October 19, 2021*ING-CC-0199Empaveli (pegcetacoplan)New
October 19, 2021ING-CC-0163ING-CC-0163Durysta (bimatoprost implant)Revised
October 19, 2021*ING-CC-0111Nplate (romiplostim)Revised
October 19, 2021*ING-CC-0137Cablivi (caplacizumab-yhdp)Revised
October 19, 2021ING-CC-0165Trodelvy (sacituzumab govitecan)Revised
October 19, 2021*ING-CC-0124Keytruda (pembrolizumab)Revised
October 19, 2021*ING-CC-0128Tecentriq (atezolizumab)Revised
October 19, 2021ING-CC-0099Abraxane (paclitaxel, protein bound)Revised
October 19, 2021ING-CC-0098Doxorubicin Liposome (Doxil, Lipodox)Revised
October 19, 2021*ING-CC-0107Bevacizumab for Non-Ophthalmologic IndicationsRevised
October 19, 2021ING-CC-0127Darzalex (daratumumab)Revised
October 19, 2021ING-CC-0142Somatuline Depot (lanreotide)Revised
October 19, 2021*ING-CC-0114Jevtana (cabazitaxel)Revised
October 19, 2021ING-CC-0161Sarclisa (isatuximab-irfc)Revised
October 19, 2021ING-CC-0120Kyprolis (carfilzomib)Revised
October 19, 2021*ING-CC-0145Libtayo (cemiplimab-rwlc)Revised
October 19, 2021ING-CC-0151Yescarta (axicabtagene ciloleucel)Revised
October 19, 2021ING-CC-0150Kymriah (tisagenlecleucel)Revised
October 19, 2021ING-CC-0125Opdivo (nivolumab)Revised
October 19, 2021*ING-CC-0032Botulinum ToxinRevised
October 19, 2021*ING-CC-0160Vyepti (eptinezumab)Revised
October 19, 2021*ING-CC-0052Dihydroergotamine (DHE) injectionRevised
October 19, 2021*ING-CC-0066Monoclonal Antibodies to Interleukin-6Revised
October 19, 2021ING-CC-0064Interleukin-1 inhibitorsRevised
October 19, 2021*ING-CC-0062Tumor Necrosis Factor AntagonistsRevised
October 19, 2021*ING-CC-0102GNRH Analogs for Oncologic IndicationsRevised
October 19, 2021*ING-CC-0020Tysabri (natalizumab)Revised

For more information, visit Healthy Blue + Medicare. 

BNCCARE-0172-21 July 2021 519248MUPENMUB
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