Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the August 20, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective October 1, 2021

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

• ING-CC-0020 Tysabri (natalizumab)

 

Revised clinical criteria effective October 7, 2021

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

• ING-CC-0007 Synagis (palivizumab)

 

Revised clinical criteria effective November 1, 2021

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

• ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
• ING-CC-0167 Rituximab Agents for Oncologic Indications

 

The following clinical criteria documents were endorsed at the September 22, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective October 4, 2021

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

• ING-CC-0125 Opdivo (nivolumab)
• ING-CC-0197 Jemperli (dostarlimab-gxly)

 

Revised clinical criteria effective October 25, 2021

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

• ING-CC-0008 Subcutaneous Hormonal Implants
• ING-CC-0013 Mepsevii (vestronidase alfa)
• ING-CC-0015 Infertility and HCG Agents
• ING-CC-0022 Vimizim (elosulfase alfa)
• ING-CC-0023 Naglazyme (galsulfase)
• ING-CC-0024 Elaprase (idursulfase)
• ING-CC-0025 Aldurazyme (laronidase)
• ING-CC-0027 Denosumab Agents
• ING-CC-0028 Benlysta (belimumab)
• ING-CC-0046 Zinplava (bezlotoxumab)
• ING-CC-0078 Orencia (abatacept)

 

Revised clinical criteria effective March 1, 2022

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-0012 Brineura (cerliponase alfa)
• ING-CC-0017 Xiaflex (collagenase clostridium histolyticum) injection
• ING-CC-0018 Agents for Pompe Disease
• ING-CC-0021 Fabrazyme (agalsidase beta)
• ING-CC-0034 Hereditary Angioedema Agents
• ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
• ING-CC-0099 Abraxane (paclitaxel, protein bound)
• ING-CC-0100 Istodax (romidepsin)
• ING-CC-0124 Keytruda (pembrolizumab)
• ING-CC-0125 Opdivo (nivolumab)
• ING-CC-0128 Tecentriq (atezolizumab)

 

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