CommercialJuly 31, 2019
Clinical criteria updates for specialty pharmacy
Below are clinical criteria that were endorsed at the May 17, 2019 clinical criteria meeting. To access the clinical criteria information please click here.
If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Revised clinical criteria effective June 10, 2019
The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
Clinical or Coverage Guideline |
Clinical Criteria |
Clinical Criteria Name |
Drug(s) |
HCPCS or CPT Code(s) |
CG-DRUG-106 |
ING-CC-0092 |
Adcetris (brentuximab) |
Adcetris |
J9042 |
CG-DRUG-38 |
ING-CC-0094 |
Alimta (pemetrexed) |
Alimta |
J9305 |
CG-DRUG-42 |
ING-CC-0096 |
Asparagine Specific Enzymes |
Erwinaze, Asparaginase, Oncaspar |
J9019, J9020, J9266 |
CG-DRUG-63 |
ING-CC-0104 |
Leucovorin and Levoleucovorin agents |
Fusilev, Khapzory |
J0641, C9043, J3490 |
CG-DRUG-66 |
ING-CC-0105 |
Vectibix (panitumumab) |
Vectibix |
J9303 |
CG-DRUG-72 |
ING-CC-0110 |
Perjeta (pertuzumab) |
Perjeta |
J9306 |
CG-DRUG-96 |
ING-CC-0115 |
Kadcyla (ado-trastuzumab) |
Kadcyla |
J9354 |
CG-DRUG-98 |
ING-CC-0116 |
Bendamustine agents |
Bendeka, Treanda, Belrapzo |
J9034, J9033, C9042, J9999 |
DRUG.00046 |
ING-CC-0119 |
Yervoy (ipilimumab) |
Yervoy |
J9228 |
DRUG.00053 |
ING-CC-0120 |
Kyprolis (carfilzomib) |
Kyprolis |
J9047 |
DRUG.00063 |
ING-CC-0122 |
Arzerra (ofatumumab) |
Arzerra |
J9302 |
DRUG.00067 |
ING-CC-0123 |
Cyramza (ramucirumab) |
Cyramza |
J9308 |
DRUG.00071 |
ING-CC-0124 |
Keytruda (pembrolizumab) |
Keytruda |
J9271 |
DRUG.00075 |
ING-CC-0125 |
Opdivo (nivolumab) |
Opdivo |
J9299 |
DRUG.00107 |
ING-CC-0129 |
Bavencio (avelumab) |
Bavencio |
J9023 |
Revised clinical criteria effective September 1, 2019
The following new clinical criteria were reviewed with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
Clinical or Coverage Guideline |
Clinical Criteria |
Clinical Criteria Name |
Drug(s) |
HCPCS or CPT Code(s) |
CG-DRUG-100 |
ING-CC-0085 |
Actimmune (interferon gamma-1B) |
Actimmune |
J9216 |
CG-DRUG-101 |
ING-CC-0090 |
Ixempra (ixabepilone) |
Ixempra |
J9207 |
CG-DRUG-102 |
ING-CC-0091 |
Lartruvo (olaratumab) |
Lartruvo |
J9285 |
CG-DRUG-49 |
ING-CC-0098 |
Doxorubicin Hydrochloride Liposome |
Lipodox, Doxorubicin hydrochloride liposomal, Doxil |
Q2049, Q2050 |
CG-DRUG-50 |
ING-CC-0099 |
Abraxane (paclitaxel protein-bound) |
Abraxane |
J9264 |
CG-DRUG-51 |
ING-CC-0100 |
Istodax (romidepsin) |
Istodax |
J9315 |
CG-DRUG-62 |
ING-CC-0103 |
Faslodex (fulvestrant) |
Faslodex |
J9395 |
CG-DRUG-67 |
ING-CC-0106 |
Erbitux (cetuximab) |
Erbitux |
J9055 |
CG-DRUG-68 |
ING-CC-0107 |
Bevacizumab agents (Avastin, Mvasi) |
Avastin, Mvasi |
J9035, Q5107 |
CG-DRUG-70 |
ING-CC-0108 |
Halaven (eribulin) |
Halaven |
J9179 |
CG-DRUG-71 |
ING-CC-0109 |
Zaltrap (ziv-aflibercept) |
Zaltrap |
J9400 |
CG-DRUG-75 |
ING-CC-0111 |
Nplate (romiplostim) |
Nplate |
J2796 |
CG-DRUG-77 |
ING-CC-0112 |
Xofigo (Radium Ra 223 Dichloride) |
Xofigo |
A9606, 79101 |
CG-DRUG-80 |
ING-CC-0114 |
Jevtana (cabazitaxel) |
Jevtana |
J9043 |
CG-DRUG-99 |
ING-CC-0117 |
Empliciti (elotuzumab) |
Empliciti |
J9176 |
CG-THER-RAD-03 |
ING-CC-0118 |
Radioimmunotherapy: Zevalin; azedra; Lutathera |
Zevalin, Azedra, Lutathera |
79403, A9543, 79101, A9699, C9408, A9513 |
DRUG.00062 |
ING-CC-0121 |
Gazyva (obinutuzumab) |
Gazyva |
J9301 |
DRUG.00076 |
ING-CC-0126 |
Blincyto (blinatumomab) |
Blincyto |
J9039 |
DRUG.00082 |
ING-CC-0127 |
Darzalex (daratumumab) |
Darzalex |
J9145 |
DRUG.00088 |
ING-CC-0128 |
Tecentriq (atezolizumab) |
Tecentriq |
J9022 |
DRUG.00109 |
ING-CC-0130 |
Imfinzi (durvalumab) |
Imfinzi |
J9173 |
CG-DRUG-113 |
ING-CC-0131 |
Besponsa (inotuzumab ozogamicin) |
Besponsa |
J9229 |
DRUG.00112 |
ING-CC-0132 |
Mylotarg (gemtuzumab ozogamicin) |
Mylotarg |
J9203 |
DRUG.00118 |
ING-CC-0133 |
Aliqopa (copanlisib) |
Aliqopa |
J9057 |
MED.00106 |
ING-CC-0134 |
Provenge (Sipuleucel-T) |
Provenge |
Q2043 |
CG-MED-67 |
ING-CC-0135 |
Melanoma Vaccines |
Imlygic |
J9325, J3590 |
CG-DRUG-53 |
ING-CC-0136 |
Drug dosage, frequency, and route of administration |
N/A |
N/A |
CG-DRUG-01 |
ING-CC-0141 |
Off-Label Drug and Approved Orphan Drug Use |
N/A |
N/A |
Revised clinical criteria effective November 1, 2019
The following current and new clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0048 Spinraza (nusinersen)
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0113 Sylvant (siltuximab) [previously CG-DRUG-79]
New clinical criteria effective November 1, 2019
The following clinical criteria are new.
- ING-CC-0137 Cablivi (caplacizumab-yhdp)
- ING-CC-0138 Asparlas (calaspargase pegol-mknl)
- ING-CC-0139 Evenity (romosozumab-aqqg)
- ING-CC-0140 Zulresso (brexanolone)
PUBLICATIONS: August 2019 Anthem Connecticut Provider News
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