Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the May 15, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised clinical criteria effective May 28, 2020

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

• ING-CC-0031 - Intravitreal Corticosteroid Implants

 

Revised clinical criteria effective June 15, 2020

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

• ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
• ING-CC-0092 - Adcetris (brentuximab vedotin)
• ING-CC-0098 - Doxorubicin Liposome (Doxil, Lipodox)
• ING-CC-0099 - Abraxane (paclitaxel, protein bound)
• ING-CC-0107 - Bevacizumab for Non-Ophthalmologic Indications
• ING-CC-0124 - Keytruda (pembrolizumab)
• ING-CC-0128 - Tecentriq (atezolizumab)
• ING-CC-0111 - Nplate (romiplostim)
• ING-CC-0127 - Darzalex (daratumumab)

 

Revised clinical criteria effective June 15, 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-0045 - Increlex (mecasermin)
• ING-CC-0069 - Egrifta (tesamorelin)
• ING-CC-0114 - Jevtana (cabazitaxel)
• ING-CC-0116 - Bendamustine agents
• ING-CC-0119 - Yervoy (ipilimumab)
• ING-CC-0125 - Opdivo (nivolumab)
• ING-CC-0137 - Cablivi (caplacizumab-yhdp)
• ING-CC-0142 - Somatuline Depot (lanreotide)
• ING-CC-0143 - Polivy (polatuzumab vedotin-piiq)
• ING-CC-0145 - Libtayo (cemiplimab-rwlc)
• ING-CC-0151 - Yescarta (axicabtagene ciloleucel)

 

Revised clinical criteria effective October 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-0003 - Immunoglobulins
• ING-CC-0032 - Botulinum Toxin
• ING-CC-0044 - Exondys 51 (eteplirsen)
• ING-CC-0057 - Krystexxa (pegloticase)
• ING-CC-0068 - Growth Hormone
• ING-CC-0098 - Doxorubicin Liposome (Doxil, Lipodox)
• ING-CC-0099 - Abraxane (paclitaxel, protein bound)
• ING-CC-0105 - Vectibix (panitumumab)
• ING-CC-0106 - Erbitux (cetuximab)
• ING-CC-0107 - Bevacizumab for Non-Ophthalmologic Indications
• ING-CC-0124 - Keytruda (pembrolizumab)
• ING-CC-0128 - Tecentriq (atezolizumab)
• ING-CC-0134 - Provenge (sipuleucel-T)
• ING-CC-0152 - Vyondys 53 (golodirsen)
• ING-CC-0153 - Adakveo (crizanlizumab)
• ING-CC-0162 - Tepezza (teprotumumab-trbw)
• ING-CC-0163 - Durysta (bimatoprost implant)

 

530-0720-PN-NE