Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the February 19, 2021, Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

New clinical criteria effective February 25, 2021

The following clinical criteria are new.

• ING-CC-0186 Margenza (margetuximab-cmkb)
• ING-CC-0187 Breyanzi (lisocabtagene maraleucel)

 

Revised clinical criteria effective February 25, 2021

The following current clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0028: Benlysta (belimumab)
• ING-CC-0094: Pemetrexed Agents (Alimta, Pemfexy)
• ING-CC-0107: Bevacizumab agents (Avastin, Mvasi)
• ING-CC-0167: Rituximab Agents for Oncologic Indications Step Therapy

 

Reviewed clinical criteria effective February 25, 2021

The following current clinical criteria were reviewed and may have word changes or clarifications, but had no significant changes to the position or criteria.

• ING-CC-0002: Colony Stimulating Factor Agents

 

New clinical criteria effective March 16, 2021

The following clinical criteria is new.

• ING-CC-0189: Amondys 45 (casimersen)
• ING-CC-0190: Nulibry (fosdenopterin)

 

Revised clinical criteria effective March 23, 2021

The following current clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0033: Xolair (omalizumab)
• ING-CC-0043: Monoclonal Antibodies to Interleukin-5
• ING-CC-0099: Abraxane (paclitaxel, protein bound)
• ING-CC-0119: Yervoy (ipilimumab)
• ING-CC-0125: Opdivo (nivolumab)
• ING-CC-0157: Padcev (enfortumab vedotin)
• ING-CC-0158: Enhertu (fam-trastuzumab deruxtecan-nxki)

 

Coding update effective March 23, 2021

The following clinical criteria was updated with new procedure and/or diagnosis codes.

• ING-CC-0115: Kadcyla (ado-trastuzumab)

 

Reviewed clinical criteria effective March 23, 2021

The following current clinical criteria were reviewed and may have word changes or clarifications, but had no significant changes to the position or criteria.

• ING-CC-0011: Ocrevus (ocrelizumab)
• ING-CC-0027: Denosumab Agents
• ING-CC-0085: Actimmune (interferon gamma-1B)
• ING-CC-0088: Elzonris (tagraxofusp-erzs)
• ING-CC-0089: Mozobil (plerixafor)
• ING-CC-0090: Ixempra (ixabepilone)
• ING-CC-0091: Lartruvo (olaratumab)
• ING-CC-0096: Asparagine Specific Enzymes: Oncaspar (pegaspargase), Erwinaze (asparaginase [erwinia chrysanthemi])
• ING-CC-0103: Faslodex (fulvestrant)
• ING-CC-0108: Halaven (eribulin)
• ING-CC-0109: Zaltrap (ziv-aflibercept)
• ING-CC-0110: Perjeta (pertuzumab)
• ING-CC-0112: Xofigo (Radium Ra 223 Dichloride)
• ING-CC-0113: Sylvant (siltuximab)
• ING-CC-0117: Empliciti (elotuzumab)
• ING-CC-0118: Radioimmunotherapy: Zevalin; azedra; Lutathera
• ING-CC-0120: Kyprolis (carfilzomib)
• ING-CC-0121: Gazyva (obinutuzumab)
• ING-CC-0122: Arzerra (ofatumumab)
• ING-CC-0126: Blincyto (blinatumomab)
• ING-CC-0129: Bavencio (avelumab)
• ING-CC-0130: Imfinzi (durvalumab)
• ING-CC-0131: Besponsa (inotuzumab ozogamicin)
• ING-CC-0132: Mylotarg (gemtuzumab ozogamicin)
• ING-CC-0135: Melanoma Vaccines
• ING-CC-0140: Zulresso (brexanolone)
• ING-CC-0156: Reblozyl (luspatercept)
• ING-CC-0160: Vyepti (eptinezumab-jjmr)
• ING-CC-0164: Jelmyto (mitomycin gel)

 

New clinical criteria effective July 1, 2021

The following clinical criteria is new.

• ING-CC-0188: Imcivree (setmelanotide)

 

Revised clinical criteria effective July 1, 2021

The following current 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-0028: Benlysta (belimumab)
• ING-CC-0034: Hereditary Angioedema Agents
• ING-CC-0043: Monoclonal Antibodies to Interleukin-5
• ING-CC-0067: Prostacyclin Infusion and Inhalation Therapy
• ING-CC-0075: Rituxan (rituximab) for Non-Oncologic Indications
• ING-CC-0086: Spravato (esketamine) Nasal Spray
• ING-CC-0094: Pemetrexed Agents (Alimta, Pemfexy)
• ING-CC-0115: Kadcyla (ado-trastuzumab)
• ING-CC-0119: Yervoy (ipilimumab)
• ING-CC-0123: Cyramza (ramucirumab)
• ING-CC-0125: Opdivo (nivolumab)
• ING-CC-0157: Padcev (enfortumab vedotin)

 

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