Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the August 16, 2024, Clinical Criteria meeting. Visit Clinical Criteria In Pharmacy to access the Clinical Criteria information.

New Clinical Criteria effective January 1, 2025

The following Clinical Criteria are new:

• CC-0266 Rytelo (imetelstat)

Revised Clinical Criteria effective January 1, 2025

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-0003 Immunoglobulins
• CC-0007 Synagis (palivizumab)
• CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
• CC-0027 Denosumab Agents
• CC-0028 Benlysta (belimumab)
• CC-0029 Dupixent (dupilumab)
• CC-0048 Spinraza (nusinersen)
• CC-0058 Octreotide Agents
• CC-0082 Onpattro (patisiran)
• CC-0193 Evkeeza (evinacumab)
• CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended -release) Injection
• CC-0207 Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)
• CC-0217 Amvuttra (vulrisiran)
• CC-0246 Rystiggo (rozanolixizumab-noli)