Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the November 17, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective May 1, 2024

The following Clinical Criteria are new:

• CC-0253 Aphexda (motixafortide)
• CC-0254 Zilbysq (zilucoplan)

Revised Clinical Criteria effective May 1, 2024

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CC-0002 Colony Stimulating Factor Agents
• CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
• CC-0011 Ocrevus (ocrelizumab)
• CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
• CC-0020 Natalizumab Agents (Tysabri, Tyruko)
• CC-0032 Botulinum Toxin
• CC-0041 Complement Inhibitors
• CC-0042 Monoclonal Antibodies to Interleukin-17
• CC-0050 Monoclonal Antibodies to Interleukin-23
• CC-0062 Tumor Necrosis Factor Antagonists
• CC-0063 Ustekinumab Agents (Stelara, Wezlana)
• CC-0064 Interleukin-1 Inhibitors
• CC-0065 Agents for Hemophilia A and von Willebrand Disease
• CC-0066 Monoclonal Antibodies to Interleukin-6
• CC-0068 Growth Hormone
• CC-0071 Entyvio (vedolizumab)
• CC-0078 Orencia (abatacept)
• CC-0086 Spravato (esketamine) Nasal Spray
• CC-0170 Uplizna (inebilizumab-cdon)
• CC-0173 Enspryng (satralizumab-mwge)
• CC-0174 Kesimpta (ofatumumab)
• CC-0182 Iron Agents
• CC-0199 Empaveli (pegcetacoplan)
• CC-0226 Elahere (mirvetuximab)