Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the November 20, 2020, Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective December 3, 2020

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

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

 

Revised clinical criteria effective December 9, 2020

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

• ING-CC-0011: Ocrevus (ocrelizumab)
• ING-CC-0174: Kesimpta (ofatumumab)

 

Revised clinical criteria effective December 21, 2020

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

• ING-CC-0003: Immunoglobulins
• ING-CC-0034: Hereditary Angioedema Agents
• ING-CC-0042: Monoclonal Antibodies to Interleukin-17
• ING-CC-0062: Tumor Necrosis Factor Antagonists
• ING-CC-0063: Stelara (ustekinumab)
• ING-CC-0065: Agents for Hemophilia A and von Willebrand Disease
• ING-CC-0072: Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
• ING-CC-0075: Rituximab Agents for Non-Oncologic Indications
• ING-CC-0121: Gazyva (obinutuzumab)
• ING-CC-0148: Agents for Hemophilia B
• ING-CC-0149: Select Clotting Agents for Bleeding Disorders

 

Reviewed clinical criteria effective December 21, 2020

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

• ING-CC-0001: Erythropoiesis Stimulating Agents
• ING-CC-0006: Hyaluronan Injections
• ING-CC-0014: Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
• ING-CC-0040: Prialt (ziconotide)
• ING-CC-0047: Trogarzo (ibalizumab-uiyk)
• ING-CC-0049: Radicava (edaravone)
• ING-CC-0074: Akynzeo (fosnetupitant and palonosetron) for injection
• ING-CC-0107: Bevacizumab for Non-Ophthalmologic Indications
• ING-CC-0133: Aliqopa (copanlisib)
• ING-CC-0150: Kymriah (tisagenlecleucel)
• ING-CC-0151: Yescarta (axicabtagene ciloleucel)
• ING-CC-0155: Ethyol (amifostine)
• ING-CC-0166: Trastuzumab Agents Step Therapy
• ING-CC-0167: Rituximab Agents for Oncologic Indications Step Therapy
• ING-CC-0173: Enspryng (satralizumab-mwge)

 

New clinical criteria effective May 1, 2021

The following clinical criteria is new.

• ING-CC-0183: Sogroya (somapacitan-beco)

 

Revised clinical criteria effective May 1, 2021

The following 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-0011: Ocrevus (ocrelizumab)
• ING-CC-0027: Denosumab Agents
• ING-CC-0034: Hereditary Angioedema Agents
• ING-CC-0039: GamaSTAN [immune globulin (human)]
• ING-CC-0041: Complement Inhibitors
• ING-CC-0042: Monoclonal Antibodies to Interleukin-17
• 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-0066: Monoclonal Antibodies to Interleukin-6
• ING-CC-0071: Entyvio (vedolizumab)
• ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy
• ING-CC-0078: Orencia (abatacept)
• ING-CC-0121: Gazyva (obinutuzumab)
• ING-CC-0148: Agents for Hemophilia B
• ING-CC-0174: Kesimpta (ofatumumab)

 

The following clinical criteria documents were endorsed at the December 18, 2020, Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective December 22, 2020

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

• ING-CC-0124: Keytruda (pembrolizumab)

 

New clinical criteria effective December 22, 2020

The following clinical criteria is new.

• ING-CC-0184: Danyelza (naxitamab-gqgk)

 

Revised clinical criteria effective January 25, 2021

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

• ING-CC-0002: Colony Stimulating Factor Agents
• ING-CC-0015: Infertility and HCG Agents
• ING-CC-0032: Botulinum Toxin
• ING-CC-0154: Givlaari (givosiran)

 

Reviewed clinical criteria effective January 25, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

• ING-CC-0079: Strensiq (Asfotase Alfa)
• ING-CC-0177: Zilretta (triamcinolone acetonide extended-release)

 

New clinical criteria effective May 1, 2021

The following clinical criteria is new.

• ING-CC-0185: Oxlumo (lumasiran)

 

Revised clinical criteria effective May 1, 2021

The following 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-0032: Botulinum Toxin
• ING-CC-0154: Givlaari (givosiran)

 

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