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June 2022 Clinical Criteria Updates (Healthy Blue + Medicare HMO D-SNP) November 21, 2022 Pharmacy

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).

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 3, 2023*ING-CC-0217Amvuttra (vutrisiran)New
February 3, 2023*ING-CC-0218Xipere (triamcinolone acetonide) for suprachoroidal useNew
February 3, 2023ING-CC-0119Yervoy (ipilimumab)Revised
February 3, 2023ING-CC-0125Opdivo (nivolumab)Revised
February 3, 2023ING-CC-0150Kymriah (tisagenlecleucel)Revised
February 3, 2023ING-CC-0067Prostacyclin infusion and inhalation therapyRevised
February 3, 2023ING-CC-0041Complement inhibitorsRevised
February 3, 2023*ING-CC-0003ImmunoglobulinsRevised
February 3, 2023*ING-CC-0061Gonadotropin releasing hormone analogs for the treatment of non-oncologic indicationsRevised
February 3, 2023ING-CC-0015Infertility and HCG agentsRevised
February 3, 2023*ING-CC-0097Vidaza (azacitidine)Revised
February 3, 2023*ING-CC-0072Vascular endothelial growth factor (VEGF) inhibitorsRevised
February 3, 2023*ING-CC-0107Bevacizumab for non-ophthalmologic indicationsRevised
February 3, 2023*ING-CC-0002Colony stimulating factor agentsRevised

For more information, visit Healthy Blue + Medicare.

NCBCBS-CR-006386-22-CPN5937 October 2022