Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the November 15, 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 December 16, 2019

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

• ING-CC-0003: Immunoglobulins
• ING-CC-0041: Complement Inhibitors
• ING-CC-0042: Monoclonal Antibodies to Interleukin-17
• ING-CC-0063: Stelara (ustekinumab)
• ING-CC-0065: Agents for Hemophilia A and von Willebrand Disease
• ING-CC-0075: Rituximab Agents for Non-Oncology Indications
• ING-CC-0124: Keytruda (pembrolizumab)
• ING-CC-0127: Darzalex (daratumumab)
• ING-CC-0128: Tecentriq (atezolizumab)
• ING-CC-0133: Aliqopa (copanlisib)

 

Revised clinical criteria effective December 16, 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-0002: Colony Stimulating Factor Agents
• ING-CC-0006: Hyaluronan Injections
• ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)
• ING-CC-0039: GamaSTAN [immune globulin (human)]
• ING-CC-0040: Prialt (ziconotide)
• ING-CC-0043: Monoclonal Antibodies to Interleukin-5
• ING-CC-0047: Trogarzo (ibalizumab-uiyk)
• ING-CC-0049: Radicava (edaravone)
• ING-CC-0062: Tumor Necrosis Factor Antagonists
• ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy
• ING-CC-0074: Akynzeo (fosnetupitant and palonosetron) for Injection
• ING-CC-0079: Strensiq (asfotase alfa)
• ING-CC-0090: Ixempra (ixabepilone)
• ING-CC-0100: Istodax (romidepsin)
• ING-CC-0103: Faslodex (fulvestrant)
• ING-CC-0108: Halaven (eribulin)
• ING-CC-0110: Perjeta (pertuzumab)
• ING-CC-0115: Kadcyla (ado-trastuzumab)

 

New clinical criteria effective February 5, 2020

The following new clinical criteria was previously a medical policy and was revised to expand medical necessity indications or criteria.

• ING-CC-0151: Yescarta (axicabtagene ciloleucel) (previously MED.00123)

 

New clinical criteria effective February 5, 2020

The following new clinical criteria was previously a medical policy and was revised with no significant change to the medical necessity indications or criteria.

• ING-CC-0150: Kymriah (tisagenlecleucel) (previously MED.00124)

 

Revised clinical criteria effective May 1, 2020

The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

• ING-CC-0002: Colony Stimulating Factor Agents
• ING-CC-0003: Immunoglobulins
• ING-CC-0034: Hereditary Angioedema Agents
• ING-CC-0041: Complement Inhibitors
• ING-CC-0042: Monoclonal Antibodies to Interleukin-17
• ING-CC-0043: Monoclonal Antibodies to Interleukin-5
• ING-CC-0048: Spinraza (nusinersen)
• ING-CC-0050: Monoclonal Antibodies to Interleukin-23
• ING-CC-0062: Tumor Necrosis Factor Antagonists
• ING-CC-0063: Stelara (ustekinumab)
• ING-CC-0064: Interleukin-1 Inhibitors
• ING-CC-0065: Agents for Hemophilia A and von Willebrand Disease
• 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-0078: Orencia (abatacept)
• ING-CC-0150: Kymriah (tisagenlecleucel)

 

New clinical criteria effective May 1, 2020

The following new clinical criteria had content transferred from existing criteria and was revised with no significant change to the medical necessity indications or criteria.

• ING-CC-0148: Agents for Hemophilia B (content moved from ING-CC-0065)

 

New clinical criteria effective May 1, 2020

The following new clinical criteria had content transferred from existing criteria and was revised, which might result in services that were previously covered but may now be found to be not medically necessary.

• ING-CC-0149: Select Clotting Agents for Bleeding Disorders (content moved from ING-CC-0065)