The following clinical criteria documents were endorsed at the August 20, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective September 1, 2021

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

  • ING-CC-0020: Tysabri (natalizumab)
  • ING-CC-0062: Tumor Necrosis Factor Antagonists
  • ING-CC-0124: Keytruda (pembrolizumab)

 

Revised clinical criteria effective September 1, 2021

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

  • ING-CC-0007: Synagis (palivizumab)


Revised clinical criteria effective September 20, 2021

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

  • ING-CC-0004: H.P. Acthar Gel (repository corticotropin injection)
  • ING-CC-0011: Ocrevus (ocrelizumab)
  • ING-CC-0014: Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
  • ING-CC-0030: Implantable and ER Buprenorphine Containing Agents
  • ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)
  • ING-CC-0036: Naltrexone Implantable Pellets
  • ING-CC-0044: Exondys 51 (eteplirsen)
  • ING-CC-0058: Octreotide Agents
  • ING-CC-0082: Onpattro (patisiran)
  • ING-CC-0100: Istodax (romidepsin)
  • ING-CC-0139: Evenity (romosozumab-aqqg)
  • ING-CC-0144: Lumoxiti (moxetumomab pasudotox-tdfk)
  • ING-CC-0152: Vyondys 53 (golodirsen)
  • ING-CC-0167: Rituximab Agents for Oncologic Indications Step Therapy
  • ING-CC-0172: Viltepso (viltolarsen)
  • ING-CC-0174: Kesimpta (ofatumumab)
  • ING-CC-0176: Beleodaq (belinostat)
  • ING-CC-0179: Blenrep (belantamab mafodotin-blmf)
  • ING-CC-0180: Monjuvi (tafasitamab-cxix)
  • ING-CC-0181: Veklury (remdesivir)
  • ING-CC-0189: Amondys 45 (casimersen)
  • ING-CC-0191: Pepaxto (melphalan flufenamide; melflufen)

 

Revised clinical criteria effective September 20, 2021

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

  • ING-CC-0001: Erythropoiesis Stimulating Agents
  • ING-CC-0010: Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
  • ING-CC-0038: Human Parathyroid Hormone Agents
  • ING-CC-0075: Rituximab Agents for Non-Oncologic Indications
  • ING-CC-0104: Levoleucovorin Agents
  • ING-CC-0169: Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
  • ING-CC-0193: Evkeeza (evinacumab)

 

Revised clinical criteria effective October 1, 2021

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

  • ING-CC-0100: Istodax (romidepsin)
  • ING-CC-0126: Blincyto (blinatumomab)
  • ING-CC-0150: Kymriah (tisagenlecleucel)
  • ING-CC-0151: Yescarta (axicabtagene ciloleucel)
  • ING-CC-0168: Tecartus (brexucabtagene autoleucel)
  • ING-CC-0171: Zepzelca (lurbinectedin)
  • ING-CC-0173: Enspryng (satralizumab-mwge)
  • ING-CC-0182: Iron Agents
  • ING-CC-0187: Breyanzi (lisocabtagene maraleucel)
  • ING-CC-0189: Amondys 45 (casimersen)
  • ING-CC-0191: Pepaxto (melphalan flufenamide; melflufen)
  • ING-CC-0192: Cosela (trilaciclib)
  • ING-CC-0193: Evkeeza (evinacumab)
  • ING-CC-0194: Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
  • ING-CC-0195: Abecma (idecabtagene vicleucel)
  • ING-CC-0196: Zynlonta (loncastuximab tesirine-lpyl)
  • ING-CC-0197: Jemperli (dostarlimab)
  • ING-CC-0201: Rybrevant (amivantamab-ymjw)

 

New clinical criteria effective January 1, 2022

The following clinical criteria are new.

  • ING-CC-0202: Saphnelo (anifrolumab-fnia)
  • ING-CC-0203: Breyanzi Ryplazim (plasminogen, human-tvmh)

 

Revised clinical criteria effective January 1, 2022

The following criteria listed below might result in services that were previously covered, but now being considered not medically necessary.

  • ING-CC-0001: Erythropoiesis Stimulating 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-0027: Denosumab Agents
  • ING-CC-0029: Dupixent (dupilumab)
  • ING-CC-0034: Hereditary Angioedema Agents
  • ING-CC-0038: Human Parathyroid Hormone Agents
  • ING-CC-0081: Crysvita (burosumab-twza)
  • ING-CC-0096: Asparagine Specific Enzymes
  • ING-CC-0104: Levoleucovorin Agents
  • ING-CC-0156: Reblozyl (luspatercept)
  • ING-CC-0182: Agents for Iron Deficiency Anemia

 

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Featured In:
October 2021 Anthem Maine Provider News