Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the August 16, 2019 clinical criteria meeting. To access the clinical criteria information 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.

 

Revised clinical criteria effective September 23, 2019

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

ING-CC-0011 Ocrevus (ocrelizumab)

ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

ING-CC-0027 Denosumab Agents

ING-CC-0028 Benlysta (belimumab)

ING-CC-0029 Dupixent (dupilumab)

ING-CC-0030 Implantable and ER Buprenorphine Containing Agents

ING-CC-0038 Human Parathyroid Hormone Agents

ING-CC-0041 Complement Inhibitors

ING-CC-0075 Rituximab Agents for Non-Oncology Indications

ING-CC-0082 Onpattro (patisiran)

ING-CC-0105 Vectibix (panitumumab)

ING-CC-0114 Jevtana (cabazitaxel)

ING-CC-0124 Keytruda (pembrolizumab)

ING-CC-0127 Darzalex (daratumumab)

ING-CC-0128 Tecentriq (atezolizumab)

ING-CC-0134 Provenge (sipuleucel-T)

 

Revised clinical criteria effective September 23, 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-0004 H.P. Acthar Gel (repository corticotropin injection)

ING-CC-0008 Subcutaneous Hormonal Implants

ING-CC-0009 Lemtrada (alemtuzumab)

ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors

ING-CC-0020 Tysabri (natalizumab)

ING-CC-0036 Naltrexone Implantable Pellets

ING-CC-0044 Exondys 51 (eteplirsen)

ING-CC-0094 Alimta (pemetrexed disodium)

ING-CC-0099 Abraxane (paclitaxel, protein bound)

ING-CC-0104 Levoleucovorin Agents

ING-CC-0119 Yervoy (ipilimumab)

ING-CC-0125 Opdivo (nivolumab)

ING-CC-0129 Bavencio (avelumab)

ING-CC-0130 Imfinzi (durvalumab)

 

New clinical criteria effective September 23, 2019

(The following are new clinical criteria.)

ING-CC-0142 Somatuline Depot (lanreotide)

ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)

 

Revised clinical criteria effective October 1, 2019

(The following current clinical criteria were updated with new procedure and/or diagnosis codes.)

ING-CC-0006 Hyaluronan Injections

ING-CC-0034 Hereditary Angioedema Agents

ING-CC-0041 Complement Inhibitors

ING-CC-0082 Onpattro (patisiran)

ING-CC-0087 Gamifant

ING-CC-0088 Elzonris (tagraxofusp-erzs)

ING-CC-0104 Levoleucovorin Agents

 

Revised clinical criteria effective December 1, 2019

(The following current clinical criteria were updated with new procedure and/or diagnosis codes.)

ING-CC-0031 Intravitreal Corticosteroid Implants

 

Revised clinical criteria effective February 1, 2020

(The following clinical criteria listed below might result in services that were previously covered, but now being considered either not medically necessary and/or investigational.)

ING-CC-0001 Erythropoiesis Stimulating Agents

ING-CC-0002 Colony Stimulating Factor Agents

ING-CC-0003 Immunoglobulins

ING-CC-0007 Synagis (palivizumab)

ING-CC-0013 Mepsevii (vestronidase alfa)

ING-CC-0018 Lumizyme (alglucosidase alfa)

ING-CC-0021 Fabrazyme (agalsidase beta)

ING-CC-0022 Vimizim (elosulfase alfa)

ING-CC-0023 Naglazyme (galsulfase)

ING-CC-0024 Elaprase (idursufase)

ING-CC-0025 Aldurazyme (laronidase)

ING-CC-0028 Benlysta (belimumab)

ING-CC-0031 Intravitreal Corticosteroid Implants

ING-CC-0032 Botulinum Toxin

ING-CC-0033 Xolair (omalizumab)

ING-CC-0034 Hereditary Angioedema Agents

ING-CC-0041 Complement Inhibitors

ING-CC-0043 Monoclonal Antibodies to Interleukin-5

ING-CC-0048 Spinraza (nusinersen)

ING-CC-0050 Monoclonal Antibodies to Interleukin-23

ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease

ING-CC-0058 Octreotide Agents

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

ING-CC-0062 Tumor Necrosis Factor Antagonists

ING-CC-0063 Stelara (ustekinumab)

ING-CC-0066 Monoclonal Antibodies to Interleukin-6

ING-CC-0071 Entyvio (vedolizumab)

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

ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy

ING-CC-0075 Rituximab Agents for Non-Oncology Indications

ING-CC-0082 Onpattro (patisiran)

ING-CC-0106 Erbitux (cetuximab)

ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications

 

New clinical criteria effective February 1, 2020

(The following are new clinical criteria.)

ING-CC-0143 Polivy (polatuzumab vedotin-piiq)

ING-CC-0145 Libtayo (cemiplimab-rwlc)