Clinical criteria updates for specialty pharmacy

ING-CC-0061 

Clinical criteria ING-CC-0061 addresses the use of gonadotropin releasing hormone analogs for the treatment of non-oncologic indications. Effective for dates of service on and after December 1, 2019, the use of Zoladex for the treatment of endometriosis will be limited to 6 months.

 

The following clinical criteria documents were endorsed at the June 20, 2019 Clinical Criteria meeting.

 

Revised clinical criteria effective July 15, 2019

(The following clinical criteria was revised to expand medical necessity indications or criteria.)

 

ING-CC-0124: Keytruda (pembrolizumab)

 

Revised clinical criteria effective July 15, 2019      

(The following clinical criteria were reviewed and may have word changes or clarifications, but had no significant changes to the medical necessity indications or criteria.)

 

ING-CC-0008: Subcutaneous Hormonal Implants

ING-CC-0048: Spinraza (nusinersen)

ING-CC-0051: Enzyme Replacement Therapy for Gaucher Disease

ING-CC-0076: Nulojix (belatacept)

ING-CC-0077: Palynziq (pegvaliase-pqpz)

 

New and revised clinical criteria effective September 1, 2019

(The following new clinical criteria were revised to expand medical necessity indications or criteria.)

 

ING-CC-0103: Faslodex (fulvestrant) [previously CG-DRUG-62]

ING-CC-0121: Gazyva (obinutuzumab) [previously DRUG.00062]

 

Revised clinical criteria effective December 1, 2019

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

 

ING-CC-0003: Immunoglobulins

ING-CC-0031: Intravitreal Corticosteroid Implants

ING-CC-0061: GnRH Analogs for the treatment of non-oncologic indications

 

To access the clinical criteria information for any of the updates above, please click here. If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.