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Clinical Criteria Updates (Healthy Blue + Medicare HMO D-SNP) January 23, 2023 Pharmacy 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)

Summary: On August 19, 2022, and September 9, 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 providers in 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 NumberClinical Criteria TitleNew or Revised
April 7, 2023*ING-CC-0219Korsuva (difelikefalin acetate)New
April 7, 2023

*ING-CC-0220

Xenpozyme (olipudase alfa)

New

April 7, 2023*ING-CC-0221Spevigo (spesolimab-sbzo)New
April 7, 2023ING-CC-0124Keytruda (pembrolizumab)Revised
April 7, 2023ING-CC-0104Levoleucovorin AgentsRevised
April 7, 2023ING-CC-0100Istodax (romidepsin)Revised
April 7, 2023ING-CC-0182

Iron Agents

Revised
April 7, 2023*ING-CC-0075Rituximab Agents for Non-Oncologic IndicationsRevised
April 7, 2023*ING-CC-0167Rituximab Agents for Oncologic Indications Step TherapyRevised
April 7, 2023

*ING-CC-0176

Beleodaq (belinostat)Revised
April 7, 2023ING-CC-0180Monjuvi (tafasitamab-cxix)Revised
April 7, 2023*ING-CC-0107Bevacizumab for non-ophthalmologic indicationsRevised
April 7, 2023*ING-CC-0002Colony Stimulating Factor AgentsRevised
April 7, 2023ING-CC-0187Breyanzi (lisocabtagene maraleucel)Revised
April 7, 2023ING-CC-0158Enhertu (fam-trastuzumab deruxtecan-nxki)Revised
April 7, 2023ING-CC-0216Opdualag (nivolumab and relatlimab-rmbw)Revised
April 7, 2023ING-CC-0196Zynlonta (loncastuximab tesirine-lpyl)Revised
April 7, 2023ING-CC-0097Vidaza (azacitidine)Revised
April 7, 2023*ING-CC-0142Somatuline Depot (lanreotide)Revised
April 7, 2023*ING-CC-0058Byngezia Pen, Sandostatin, or Sandostatin LAR (Octreotide)/ Octreotide AgentsRevised
April 7, 2023*ING-CC-0082Onpattro (patisiran)Revised
April 7, 2023*ING-CC-0084Tegsedi (inotersen)Revised
April 7, 2023*ING-CC-0034

Hereditary Angioedema Agents

Revised
April 7, 2023

ING-CC-0019

Zoledronic Acid AgentsRevised
April 7, 2023*ING-CC-0029Dupixent (dupilumab)Revised
April 7, 2023*ING-CC-0035Duopa (carbidopa and levodopa enteral suspension)Revised
April 7, 2023ING-CC-0140Zulresso (brexanolone)Revised
April 7, 2023ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Revised
April 7, 2023ING-CC-0188Imcivree (setmelanotide)Revised
April 7, 2023*ING-CC-0026Testosterone InjectableRevised
April 7, 2023*ING-CC-0207Vyvgart (efgartigimod alfa-fcab)Revised

Availity* Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. Go to Availity Essentials and select the appropriate payer space tile from the drop-down. Then select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.

Note: 

Availity, LLC is an independent company providing administrative support services for Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina. 

For more information, visit Healthy Blue + Medicare.

NCBCBS-CR-014115-22-CPN13242 December 2022

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.

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