Clinical criteria updates for specialty pharmacy

The following clinical criteria document was endorsed at the August 12, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised clinical criteria effective January 1, 2021

(The following criteria was reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)

• ING-CC-0048 - Spinraza (nusinersen)

 

The following clinical criteria documents were endorsed at the August 21, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised clinical criteria effective September 1, 2020

(The following criteria were revised to expand medical necessity indications or criteria.)

• ING-CC-0124 - Keytruda (pembrolizumab)
• ING-CC-0125 - Opdivo (nivolumab)
• ING-CC-0129 - Bavencio (avelumab)

 

New clinical criteria effective September 1, 2020

(The criteria below are new.)

• ING-CC-0169 - Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
• ING-CC-0172 - Viltepso (viltolarsen)
• ING-CC-0173 - Enspryng (satralizumab-mwge)
• ING-CC-00174 – Kesimpta (ofatumamab)

 

New clinical criteria effective September 21, 2020

(The criteria below are new.)

• ING-CC-0166 - Trastuzumab Agents Step Therapy
• ING-CC-0167 - Rituximab Agents for Oncologic Indications Step Therapy

 

Revised clinical criteria effective September 21, 2020

(The following criteria were revised to expand medical necessity indications or criteria.)

• ING-CC-0001 - Erythropoiesis Stimulating Agents
• ING-CC-0009 - Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
• ING-CC-0029 - Dupixent (dupilumab)
• ING-CC-0038 - Human Parathyroid Hormone Agents
• ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
• ING-CC-0050 - Monoclonal Antibodies to Interleukin-23
• ING-CC-0064 - Interleukin-1 Inhibitors
• ING-CC-0104 - Levoleucovorin Agents
• ING-CC-0132 - Mylotarg (gemtuzumab ozogamicin)
• ING-CC-0139 - Evenity (romosozumab-aqqg)
• ING-CC-0152 - Vyondys 53 (golodirsen)

 

Revised clinical criteria effective September 21, 2020

(The following criteria was reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)

• ING-CC-0004 - P. Acthar Gel (repository corticotropin injection)
• ING-CC-0007 - Synagis (palivizumab)
• ING-CC-0011 - Ocrevus (ocrelizumab)
• ING-CC-0014 - Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
• ING-CC-0020 - Tysabri (natalizumab)
• ING-CC-0027 - Denosumab Agents
• ING-CC-0030 - Implantable and ER Buprenorphine Containing Agents
• ING-CC-0034 - Hereditary Angioedema Agents
• ING-CC-0036 - Naltrexone Implantable Pellets
• ING-CC-0100 - Istodax (romidepsin)
• ING-CC-0141 - Off-Label Drug and Approved Orphan Drug Use
• ING-CC-0144 - Lumoxiti (moxetumomab pasudotox-tdfk)

 

Revised clinical criteria effective October 1, 2020

(The following criteria were updated with new procedure and/or diagnosis codes.)

• ING-CC-0094 - Alimta (pemetrexed disodium)
• ING-CC-0100 - Istodax (romidepsin)
• ING-CC-0127 - Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
• ING-CC-0140 - Zulresso (brexanolone)
• ING-CC-0160 - Vyepti (eptinezumab-jjmr)
• ING-CC-0161 - Sarclisa (isatuximab-irfc)
• ING-CC-0162 - Tepezza (teprotumumab-trbw)
• ING-CC-0163 - Durysta (bimatoprost implant)
• ING-CC-0165 - Trodelvy (sacituzumab govitecan)

 

New clinical criteria effective January 1, 2021

(The criteria below are new and may result in services previously covered now being considered either not medically necessary and/or investigational)

• ING-CC-0168 - Tecartus (brexucabtagene autoleucel)
• ING-CC-0170 - Uplizna (inebilizumab)
• ING-CC-0171 - Zepzelca (lurbinectedin)
• ING-CC-0175 - Proleukin (aldesleukin)
• ING-CC-0176 - Beleodaq (belinostat)
• ING-CC-0177 - Zilretta (triamcinolone acetonide extended-release)
• ING-CC-0178 - Synribo (omacetaxine mepesuccinate)

 

Revised clinical criteria effective January 1, 2021

(The following criteria listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)

• ING-CC-0001 - Erythropoiesis Stimulating Agents
• ING-CC-0002 - Colony Stimulating Factor Agents
• ING-CC-0009 - Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
• ING-CC-0010 - Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
• ING-CC-0015 - Infertility and HCG Agents
• ING-CC-0029 - Dupixent (dupilumab)
• ING-CC-0035 - Duopa (carbidopa and levodopa enteral suspension)
• ING-CC-0038 - Human Parathyroid Hormone Agents
• ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
• ING-CC-0044 - Exondys 51 (eteplirsen)
• ING-CC-0058 - Octreotide Agents
• ING-CC-0061 - GnRH Analogs for the Treatment of Non-Oncologic Indications
• ING-CC-0064 - Interleukin-1 Inhibitors
• ING-CC-0077 - Palynziq (pegvaliase-pqpz)
• ING-CC-0082 - Onpattro (patisiran)
• ING-CC-0094 - Alimta (pemetrexed disodium)
• ING-CC-0119 - Yervoy (ipilimumab)
• ING-CC-0125 - Opdivo (nivolumab)
• ING-CC-0139 - Evenity (romosozumab-aqqg)
• ING-CC-0152 - Vyondys 53 (golodirsen)

 

668-1020-PN-NE