On December 1, 2018, we introduced the new clinical criteria page for injectable, infused or implanted drugs. Effective for dates of service on and after March 1, 2019, the following new clinical criteria will be included in our clinical criteria review process. The drugs that require prior authorization will continue to require prior authorization notification with AIM. 

 

Existing precertification requirements have not changed for the specific clinical criteria below. While there are no material changes, the document number and online location has changed. To access the clinical criteria information please click here. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical Guideline/Medical Policy.

 

Pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.

 

Clinical Guideline/ Medical Policy

Clinical Criteria Document Number

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

CG-DRUG-29

ING-CC-0006

Hyaluronan Injections

Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synvisc/-One, TriVisc, Visco-3

J7318, J7320 , J7321, J7322, J7323, J7324 , J7325, J7326, J7327, J7328, J7329

DRUG.00015

ING-CC-0007

Synagis (palivizumab)

Synagis

90378

DRUG.00031

ING-CC-0008

Testopel (testosterone subcutaneous implant)

Testosterone implant

S0189

DRUG.00074

ING-CC-0009

Lemtrada (alemtuzumab)

Lemtrada

J0202

DRUG.00078

ING-CC-0010

Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors

Praluent, Repatha

J3490 , J3590

DRUG.00095

ING-CC-0011

Ocrevus (ocrelizumab)

Ocrevus

J2350

DRUG.00099

ING-CC-0012

Brineura (cerliponase alfa)

Brineura

J0567

DRUG.00116

ING-CC-0013

Mepsevii (vestronidase alfa)

Mepsevii

J3490

CG-DRUG-03

ING-CC-0014

Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

Avonex, Plegridy, Rebif, Betaseron, Extavia, Copaxone, Glatopa

J1595, J1826, J1830, J3490, Q3027, Q3028

CG-DRUG-27

ING-CC-0017

Xiaflex (clostridial collagenase histolyticum) injection

Xiaflex

J0775

CG-DRUG-28

ING-CC-0018

Lumizyme (alglucosidase alfa)

Lumizyme

J0221

CG-DRUG-43

ING-CC-0020

Tysabri (natalizumab)

Tysabri

J2323

CG-DRUG-54

ING-CC-0021

Fabrazyme (agalsidase beta)

Fabrazyme

J0180

CG-DRUG-55

ING-CC-0022

Vimizim (elosulfase alfa)

Vimizim

J1322

CG-DRUG-56

ING-CC-0023

Naglazyme (galsulfase)

Naglazyme

J1458

CG-DRUG-57

ING-CC-0024

Elaprase (idursufase)

Elaprase

J1743

CG-DRUG-58

ING-CC-0025

Aldurazyme (laronidase)

Aldurazyme

J1931

CG-DRUG-73

ING-CC-0027

Denosumab agents

Prolia, Xgeva

J0897

CG-DRUG-84

ING-CC-0028

Benlysta (belimumab)

Benlysta

J0490

CG-DRUG-88

ING-CC-0029

Dupixent (dupilumab)

Dupixent

J3490, J3590

CG-DRUG-89

ING-CC-0030

Implantable and ER Buprenorphine Containing Agents

Probuphine, Sublocade

J0570, J3490 , Q9991, Q9992

CG-DRUG-103

ING-CC-0032

Botulinum Toxin

Botox, Xeomin, Dysport, Myobloc

J0585, J0586, J0587 , J0588 , J0585, J0586 , J0587 , J0588

CG-DRUG-104

ING-CC-0033

Xolair (omalizumab)

Xolair

J2357

CG-DRUG-108

ING-CC-0035

Duopa (carbidopa and levodopa enteral suspension)

Duopa

J7340

CG-DRUG-111

ING-CC-0037

Kanuma (sebelipase alfa)

Kanuma

J2840

CG-DRUG-112

ING-CC-0038

Human Parathyroid Hormone Agents

Tymlos

J3490

DRUG.00013

ING-CC-0039

GamaSTAN [(immune globulin (human)]

GamaSTAN. GamaSTAN S/D

J1460, J1560

DRUG.00027

ING-CC-0040

Prialt (ziconotide)

Prialt

J2278

DRUG.00050

ING-CC-0041

Soliris (eculizumab)

Soliris

J1300

DRUG.00077

ING-CC-0042

Monoclonal Antibodies to Interleukin-17

Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)

C9399, J3490, J3590

DRUG.00080

ING-CC-0043

Monoclonal Antibodies to Interleukin-5

Cinqair (reslizumba), Fasenra (benralizumab), Nucala (mepolizumab)

J0517, J2182, J2786

DRUG.00081

ING-CC-0044

Exondys 51 (eteplirsen)

Exondys 51

J1428

DRUG.00086

ING-CC-0045

Increlex (mecasermin)

Increlex

J2170

DRUG.00090

ING-CC-0046

Zinplava (bezlotoxumab)

Zinplava

J0565

DRUG.00096

ING-CC-0047

Trogarzo (ibalizumab-uiyk

Trogarzo

J1746

DRUG.00104

ING-CC-0048

Spinraza (nusinersen)

Spinraza

J2326

DRUG.00108

ING-CC-0049

Radicava (edaravone)

Radicava

J1301

DRUG.00111

ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Ilumya, Tremfya

J1628, J3245

CG-DRUG-08

ING-CC-0051

Enzyme Replacement Therapy for Gaucher Disease

Cerezyme, Elelyso, Vpriv

J1786 , J3060 , J3385

CG-DRUG-44

ING-CC-0057

Krystexxa (pegloticase)

Krystexxa

J2507

CG-DRUG-45

ING-CC-0058

Octreotide Agents

Sandostatin, Sandostatin LAR Depot

J2353 , J2354

CG-DRUG-61

ING-CC-0061

GnRH Analogs for the treatment of non-oncologic indications

Zoladex, Supprelin LA, Lupron Depot/Depot-Ped, Lupaneta Pack, Synarel Nasal Spray, Triptodur

C9399, J3490, J1675, J1950, J3315, J3316, J9202 , J9217, J9218 , J9225, J9226 , J3490

CG-DRUG-69

ING-CC-0063

Stelara (ustekinumab)

Stelara

J3357, J3358

CG-DRUG-74

ING-CC-0064

Interleukin-1 Inhibitors

Arcalyst, Ilaris

J2793, J0638

CG-DRUG-93

ING-CC-0066

Monoclonal Antibodies to Interleukin-6

Actemra, Kevzara

J3262, C9399 , J3490 , J3590

CG-DRUG-82

ING-CC-0067

Prostacyclin Infusion and Inhalation Therapy

Flolan, Remodulin, Tyvaso, Veletri, Ventavis

J1325, J3285, J7686, K0455 , Q4074, S0155 , S9347

CG-DRUG-83

ING-CC-0068

Growth hormone

Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive

J2940 , J2941 , Q0515 , S9558

CG-DRUG-85

ING-CC-0069

Egrifta (tesamorelin)

Egrifta

J3490

CG-DRUG-86

ING-CC-0070

Jetrea (ocriplasmin)

Jetrea

J7316

CG-DRUG-87

ING-CC-0071

Entyvio (vedolizumab)

Entyvio

J2503 , C9257, J9035, Q5107 , J2778, J0178

CG-DRUG-92

ING-CC-0073

Alpha-1 Proteinase Inhibitor Therapy

Aralast, Glassia, Prolastin-C, Zemaira

J0256, J0257

CG-DRUG-94

ING-CC-0075

Rituxan (rituximab) for Non-Oncologic Indications

Rituxan

J9311

CG-DRUG-95

ING-CC-0076

Nulojix (belatacept)

Nulojix

J0485

CG-DRUG-105

ING-CC-0078

Orencia (abatacept)

Orencia

J0129

CG-DRUG-109

ING-CC-0079

Strensiq (asfotase alfa)

Strensiq

J3490



Featured In:
March 2019 Anthem Maine Provider Newsletter