Clinical criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the March 26, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised clinical criteria effective April 1, 2020

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

• ING-CC-0153 Adakveo (crizanlizumab)
• ING-CC-0154 Givlaari (givosiran)

 

Revised clinical criteria effective April 27, 2020

(The following criteria were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)

• ING-CC-0037 Kanuma (sebelipase alfa)
• ING-CC-0070 Jetrea (ocriplasmin)
• ING-CC-0087 Gamifant

 

Revised clinical criteria effective April 27, 2020

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

• ING-CC-0119 Yervoy (ipilimumab)
• ING-CC-0125 Opdivo (nivolumab)

 

New clinical criteria effective September 1, 2020

(The criteria below is new and may result in services previously covered now being considered either not medically necessary and/or investigational.)

• ING-CC-0161 Sarclisa (isatuximab-irfc)

 

Revised clinical criteria effective September 1, 2020

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

• ING-CC-0002 Colony Stimulating Factor Agents
• ING-CC-0058 Octreotide Agents

 

449-0620-PN-NE