Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the September 19, 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 October 14, 2019

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

• ING-CC-0015: Infertility Agents

 

Revised clinical criteria effective October 14, 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-0007: Synagis (palivizumab)
• ING-CC-0013: Mepsevii (vestronidase alfa)
• ING-CC-0017: Xiaflex (collagenase clostridium histolyticum)
• 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-0046: Zinplava (bezlotoxumab)
• ING-CC-0058: Octreotide Agents
• ING-CC-0081: Crysvita (burosumab-twza)

 

Revised clinical criteria effective March 1, 2020

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

• ING-CC-0012: Brineura (cerliponase alfa)
• ING-CC-0072: Selective Vascular Endothelial Growth Factor (VEGF) Antagonists