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Clinical Criteria Updates for Healthy Blue + MedicareSM (HMO D-SNP) February 02, 2022 Medical Policy & Clinical Guidelines

Oct. 6, 2022 Update: This communication has been updated to include effective dates.

Please note, this communication applies to Healthy Blue + MedicareSM(HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

Summary: On September 22, 2021, and November 19, 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 need additional information, use this email.

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

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
April 29, 2022*ING-CC-0204Tivdak (tisotumab vedotin-tftv)New
April 29, 2022*ING-CC-0018Lumizyme (alglucosidase alfa); Nexviazyme (avalglucosidase alfa-ngpf)Revised
April 29, 2022*ING-CC-0128Tecentriq (atezolizumab)Revised
April 29, 2022*ING-CC-0012Brineura (cerliponase alfa)Revised
April 29, 2022*ING-CC-0021Fabrazyme (agalsidase beta)Revised
April 29, 2022*ING-CC-0017Xiaflex (collagenase clostridium histolyticum)Revised
April 29, 2022*ING-CC-0026Testosterone InjectableRevised
April 29, 2022*ING-CC-0100Istodax (romidepsin)Revised
April 29, 2022*ING-CC-0125Opdivo (nivolumab)Revised
April 29, 2022ING-CC-0197Jemperli (dostarlimab-gxly)Revised
April 29, 2022ING-CC-0124Keytruda (pembrolizumab)Revised
April 29, 2022*ING-CC-0061GnRH Analogs for the Treatment of Non-Oncologic IndicationsRevised
April 29, 2022*ING-CC-0148Agents for Hemophilia BRevised
April 29, 2022*ING-CC-0149Select Clotting Agents for Bleeding DisordersRevised
April 29, 2022*ING-CC-0065Agents for Hemophilia A and von Willebrand DiseaseRevised
April 29, 2022ING-CC-0168Tecartus (brexucabtagene autoleucel)Revised
April 29, 2022*ING-CC-0195Abecma (idecabtagene vicleucel)Revised
April 29, 2022*ING-CC-0001Erythropoiesis Stimulating AgentsRevised
April 29, 2022*ING-CC-0173Enspryng (satralizumab-mwge)Revised
April 29, 2022*ING-CC-0170Uplizna (inebilizumab-cdon)Revised
April 29, 2022*ING-CC-0041Complement InhibitorsRevised
April 29, 2022*ING-CC-0071Entyvio (vedolizumab)Revised
April 29, 2022*ING-CC-0064Interleukin-1 InhibitorsRevised
April 29, 2022*ING-CC-0042Monoclonal Antibodies to Interleukin-17Revised
April 29, 2022*ING-CC-0066Monoclonal Antibodies to Interleukin-6Revised
April 29, 2022*ING-CC-0050Monoclonal Antibodies to Interleukin-23Revised
April 29, 2022*ING-CC-0078Orencia (abatacept)Revised
April 29, 2022*ING-CC-0063Stelara (ustekinumab)Revised
April 29, 2022*ING-CC-0062Tumor Necrosis Factor AntagonistsRevised
April 29, 2022ING-CC-0003ImmunoglobulinsRevised
April 29, 2022*ING-CC-0049Radicava (edaravone)Revised
April 29, 2022*ING-CC-0075Rituximab Agents for Non-Oncologic IndicationsRevised
April 29, 2022*ING-CC-0072Selective Vascular Endothelial Growth Factor (VEGF) AntagonistsRevised
April 29, 2022ING-CC-0107Bevacizumab for Non-Ophthalmologic IndicationsRevised
April 29, 2022ING-CC-0106Erbitux (cetuximab)Revised
April 29, 2022ING-CC-0105Vectibix (panitumumab)Revised
April 29, 2022ING-CC-0043Monoclonal Antibodies to Interleukin-5Revised
April 29, 2022*ING-CC-0068Growth HormoneRevised

For more information, visit Healthy Blue + Medicare

BNCCARE-0259-22 January 2022

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