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Clinical Criteria Updates (Healthy Blue + Medicare HMO D-SNP)
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 May 20, 2022, and June 23, 2022, 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, use this email.
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.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Blue Cross NC only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
| Effective Date | Document Number | Clinical Criteria Title | New or Revised |
|---|---|---|---|
| February 6, 2023 | *ING-CC-0217 | Amvuttra (vutrisiran) | New |
| February 6, 2023 | *ING-CC-0218 | Xipere (triamcinolone acetonide) for suprachoroidal use | New |
| February 6, 2023 | ING-CC-0119 | Yervoy (ipilimumab) | Revised |
| February 6, 2023 | ING-CC-0125 | Opdivo (nivolumab) | Revised |
| February 6, 2023 | ING-CC-0150 | Kymriah (tisagenlecleucel) | Revised |
| February 6, 2023 | ING-CC-0067 | Prostacyclin infusion and inhalation therapy | Revised |
| February 6, 2023 | ING-CC-0041 | Complement inhibitors | Revised |
| February 6, 2023 | *ING-CC-0003 | Immunoglobulins | Revised |
| February 6, 2023 | *ING-CC-0061 | Gonadotropin releasing hormone analogs for the treatment of non-oncologic indications | Revised |
| February 6, 2023 | ING-CC-0015 | Infertility and HCG agents | Revised |
| February 6, 2023 | *ING-CC-0097 | Vidaza (azacitidine) | Revised |
| February 6, 2023 | *ING-CC-0072 | Vascular endothelial growth factor (VEGF) inhibitors | Revised |
| February 6, 2023 | *ING-CC-0107 | Bevacizumab for non-ophthalmologic indications | Revised |
| February 6, 2023 | *ING-CC-0002 | Colony stimulating factor agents | Revised |
For more information, visit Healthy Blue + Medicare.
NCBCBS-CR-006386-22-CPN5937 October 2022
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