The following clinical criteria documents were endorsed at the June 18, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New clinical criteria effective June 26, 2020

The following clinical criteria is new.

  • ING-CC-0165 - Trodelvy (sacituzumab govitecan)

 

Revised clinical criteria effective July 20, 2020

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

  • ING-CC-0029 - Dupixent (dupilumab)
  • ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
  • ING-CC-0061 - GnRH Analogs for the Treatment of Non-Oncologic Indications
  • ING-CC-0107 - Bevacizumab for Non-Ophthalmologic Indications
  • ING-CC-0119 - Yervoy (ipilimumab)
  • ING-CC-0125 - Opdivo (nivolumab)
  • ING-CC-0128 - Tecentriq (atezolizumab)

 

Revised clinical criteria effective July 20, 2020

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

  • ING-CC-0076 - Nulojix (belatacept)
  • ING-CC-0136 - Drug Dosage, Frequency, and Route of Administration
  • ING-CC-0141 - Off-Label Drug and Approved Orphan Drug Use

 

Revised clinical criteria effective August 1, 2020

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

  • ING-CC-0043 - Monoclonal Antibodies to Interleukin-5

 

Revised clinical criteria effective October 1, 2020

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

  • ING-CC-0072 - Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

 

New clinical criteria effective November 1, 2020

The following clinical criteria is new.

  • ING-CC-0164 - Jelmyto (mitomycin gel)

 

Revised clinical criteria effective November 1, 2020

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-0002 - Colony Stimulating Factor Agents
  • ING-CC-0011 - Ocrevus (ocrelizumab)
  • ING-CC-0051 - Enzyme Replacement Therapy for Gaucher Disease
  • ING-CC-0061 - GnRH Analogs for the Treatment of Non-Oncologic Indications
  • ING-CC-0127 - Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

 

572-0820-PN-NE



Featured In:
August 2020 Anthem Maine Provider News