Clinical Criteria updates for specialty pharmacy

Visit Clinical Criteria In Pharmacy to access the Clinical Criteria information.

Revised Clinical Criteria effective May 1, 2025

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CC‑0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis*
• CC‑0041 Complement C5 Inhibitors*
• CC‑0063 Ustekinumab Agents (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Wezlana)*
• CC‑0065 Agents for Hemophilia A and von Willebrand Disease*
• CC‑0073 Alpha‑1 Proteinase Inhibitor Therapy*
• CC‑0128 Atezolizumab (Tecentriq, Tecentriq Hybreza)*
• CC‑0148 Agents for Hemophilia B*
• CC‑0149 Select Clotting Agents for Bleeding Disorders*
• CC‑0155 Ethyol (amifostine)*
• CC‑0168 Tecartus (brexucabtagene autoleucel)*
• CC‑0170 Uplizna (inebilizumab‑cdon)*
• CC‑0173 Enspryng (satralizumab‑mwge)*
• CC‑0187 Breyanzi (lisocabtagene maraleucel)*
• CC‑0195 Abecma (idecabtagene vicleucel)*
• CC‑0197 Jemperli (dostarlimab‑gxly)*
• CC‑0199 Empaveli (pegcetacoplan)*
• CC‑0214 Carvykti (ciltacabtagene autoleucel)*

* The applicable policy is attached to this article in PDF format.