Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at a Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Reviewed clinical criteria effective August 1, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

• ING-CC-0008: Subcutaneous Hormonal Implants
• ING-CC-0012: Brineura (cerliponase alfa)
• ING-CC-0013: Mepsevii (vestronidase alfa)
• ING-CC-0017: Xiaflex (collagenase clostridium histolyticum)
• ING-CC-0018: Lumizyme (alglucosidase alfa)
• ING-CC-0021: Fabrazyme (agalsidase beta)
• ING-CC-0022: Vimizim (elosulfase alfa)
• ING-CC-0023: Naglazyme (galsulfase)
• ING-CC-0024: Elaprase (idursufase)
• ING-CC-0025: Aldurazyme (laronidase)
• ING-CC-0028: Benlysta (belimumab)
• ING-CC-0029: Dupixent (dupilumab)
• ING-CC-0033: Xolair (omalizumab)
• ING-CC-0034: Hereditary Angioedema Agents
• ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)
• ING-CC-0041: Complement Inhibitors
• ING-CC-0044: Exondys 51 (eteplirsen)
• ING-CC-0049: Radicava (edaravone)
• ING-CC-0065: Agents for Hemophilia A and von Willebrand Disease
• ING-CC-0070: Jetrea (ocriplasmin)
• ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy
• ING-CC-0077: Palynziq (pegvaliase-pqpz)
• ING-CC-0079: Strensiq (asfotase alfa)
• ING-CC-0081: Crysvita (burosumab-twza)
• ING-CC-0082: Onpattro (patisiran)
• ING-CC-0148: Agents for Hemophilia B
• ING-CC-0152: Vyondys 53 (golodirsen)
• ING-CC-0156: Reblozyl (luspatercept)
• ING-CC-0159: Scenesse (afamelanotide)
• ING-CC-0170: Uplizna (inebilizumab-cdon)
• ING-CC-0172: Viltepso (viltolarsen)
• ING-CC-0173: Enspryng (satralizumab-mwge)
• ING-CC-0188: Imcivree (setmelanotide)

 

1168-0621-PN-NE