Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the May 21, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

New clinical criteria effective June 5, 2021

The criteria below is new.

• ING-CC-0199: Empaveli (pegcetacoplan)

 

Revised clinical criteria effective June 21, 2021

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

• ING-CC-0032: Botulinum Toxin
• ING-CC-0062: Tumor Necrosis Factor Antagonists
• ING-CC-0064: Interleukin-1 Inhibitors
• ING-CC-0066: Monoclonal Antibodies to Interleukin-6
• ING-CC-0098: Doxorubicin Hydrochloride Liposome
• ING-CC-0099: Abraxane (paclitaxel, protein bound)
• ING-CC-0107: Bevacizumab agents (Avastin, Mvasi)
• ING-CC-0111: Nplate (romiplostim)
• ING-CC-0120: Kyprolis (carfilzomib)
• ING-CC-0124: Keytruda (pembrolizumab)
• ING-CC-0127: Darzalex (daratumumab)
• ING-CC-0128: Tecentriq (atezolizumab)
• ING-CC-0142: Somatuline Depot (lanreotide)
• ING-CC-0150: Kymriah (tisagenlecleucel)
• ING-CC-0151: Yescarta (axicabtagene ciloleucel)
• ING-CC-0160: Vyepti (eptinezumab-jjmr)
• ING-CC-0161: Sarclisa (isatuximab-irfc)
• ING-CC-0163: Durysta (bimatoprost implant)
• ING-CC-0165: Trodelvy (sacituzumab govitecan)

 

Revised clinical criteria effective June 21, 2021

(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-0002: Colony Stimulating Factor Agents
• ING-CC-0045: Mecasermin (Increlex®)
• ING-CC-0057: Krystexxa (pegloticase)
• ING-CC-0061: GnRH Analogs for the Treatment of Non-Oncologic Indications
• ING-CC-0068: Growth hormone
• ING-CC-0069: Egrifta (tesamorelin)
• ING-CC-0087: Gamifant (emapalumab-lzsg)
• ING-CC-0092: Brentuximab Vedotin (Adcetris)
• ING-CC-0105: Vectibix (panitumumab)
• ING-CC-0106: Erbitux (cetuximab)
• ING-CC-0116: Bendamustine agents
• ING-CC-0134: Provenge (sipuleucel-T)
• ING-CC-0143: Polivy (polatuzumab vedotin-piiq)
• ING-CC-0153: Adakveo (crizanlizumab)
• ING-CC-0162: Tepezza (teprotumumab-trbw)
• ING-CC-0166: Trastuzumab Agents
• ING-CC-0171: Zepzelca (lurbinectedin)
• ING-CC-0175: Proleukin (aldesleukin)
• ING-CC-0178: Synribo (omacetaxine mepesuccinate)
• ING-CC-0183: Sogroya (somapacitan-beco)
• ING-CC-0192: Cosela (trilaciclib)
• ING-CC-0195: Abecma (idecabtagene vicleucel)

 

Revised clinical criteria effective July 1, 2021

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

• ING-CC-0125: Opdivo (nivolumab)

 

Revised clinical criteria effective July 1, 2021

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

• ING-CC-0061: GnRH Analogs for the Treatment of Non-Oncologic Indications
• ING-CC-0075: Rituximab Agents for Non-Oncology Indications
• ING-CC-0167: Rituximab Agents for Oncologic Indications Step Therapy
• ING-CC-0184: Danyelza (naxitamab-gqgk)
• ING-CC-0185: Oxlumo (lumasiran)
• ING-CC-0186: Margenza (margetuximab-cmkb)
• ING-CC-0187: Breyanzi (lisocabtagene maraleucel)
• ING-CC-0189: Amondys 45 (casimersen)
• ING-CC-0191: Pepaxto (melphalan flufenamide; melflufen)
• ING-CC-0192: Cosela (trilaciclib)
• ING-CC-0193: Evkeeza (evinacumab)
• ING-CC-0194: Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

 

New clinical criteria effective October 1, 2021

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

• ING-CC-0196: Zynlonta (loncastuximab tesirine-lpyl)
• ING-CC-0197: Jemperli (dostarlimab)
• ING-CC-0198: Relizorb (immobilized lipase) cartridge

 

Revised clinical criteria effective October 1, 2021

(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-0032: Botulinum Toxin
• ING-CC-0062: Tumor Necrosis Factor Antagonists
• ING-CC-0066: Monoclonal Antibodies to Interleukin-6
• ING-CC-0107: Bevacizumab agents (Avastin, Mvasi)
• ING-CC-0111: Nplate (romiplostim)
• ING-CC-0114: Jevtana (cabazitaxel)
• ING-CC-0124: Keytruda (pembrolizumab)
• ING-CC-0128: Tecentriq (atezolizumab)
• ING-CC-0137: Cablivi (caplacizumab-yhdp)
• ING-CC-0145: Libtayo (cemiplimab-rwlc)
• ING-CC-0160: Vyepti (eptinezumab-jjmr)

 

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