Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the February 23, 2024, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective August 1, 2024

The following Clinical Criteria are new:

• CC-0258 iDoseTR (travoprost Implant)
• CC-0260 Nexobrid (anacaulase-bcdb)

Revised Clinical Criteria effective August 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-0011 Ocrevus (ocrelizumab)
• CC-0020 Natalizumab Agents (Tysabri, Tyruko)
• CC-0029 Dupixent (dupilumab)
• CC-0033 Xolair (omalizumab)
• CC-0041 Complement Inhibitors
• CC-0043 Monoclonal Antibodies to Interleukin-5
• CC-0047 Trogarzo (ibalizumab-uiyk)
• CC-0057 Krystexxa (pegloticase)
• CC-0062 Tumor Necrosis Factor Antagonists
• CC-0064 Interleukin-1 Inhibitors
• CC-0066 Monoclonal Antibodies to Interleukin-6
• CC-0067 Prostacyclin Infusion and Inhalation Therapy
• CC-0068 Growth Hormones
• CC-0078 Orencia (abatacept)
• CC-0088 Elzonris (tagraxofusp-erzs)
• CC-0090 Ixempra (ixabepilone)
• CC-0096 Asparagine Specific Enzymes
• CC-0099 Abraxane (paclitaxel, protein-bound)
• CC-0108 Halaven (eribulin)
• CC-0112 Xofigo (Radium Ra 223 Dichloride)
• CC-0115 Kadcyla (ado-trastuzumab)
• CC-0117 Empliciti (elotuzumab)
• CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)
• CC-0119 Yervoy (ipilimumab)
• CC-0123 Cyramza (ramucirumab)
• CC-0125 Opdivo (nivolumab)
• CC-0126 Blincyto (blinatumomab)
• CC-0131 Besponsa (inotuzumab ozogamicin)
• CC-0174 Kesimpta (ofatumumab)
• CC-0199 Empaveli (pegcetacoplan)
• CC-0208 Adbry (tralokinumab)
• CC-0212 Tezspire (tezepelumab-ekko)
• CC-0227 Briumvi (ublituximab)