Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the May 20, 2022, clinical criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective May 20, 2022

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

• ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
• ING-CC-0148 Agents for Hemophilia B

 

New clinical criteria effective June 2, 2022

The following clinical criteria is new:

• ING-CC-0216 Opdualag (nivolumab and relatlimab-rmbw)

 

Revised clinical criteria effective June 2, 2022

The following clinical criteria was revised to expand medical necessity indications or criteria:

• ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

 

Revised clinical criteria effective June 20, 2022

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

• ING-CC-0002 Colony Stimulating Factor Agents
• ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
• ING-CC-0092 Adcetris (brentuximab vedotin)
• ING-CC-0106 Erbitux (cetuximab)
• ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
• ING-CC-0116 Bendamustine agents
• ING-CC-0124 Keytruda (pembrolizumab)
• ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
• ING-CC-0145 Libtayo (cemiplimab-rwlc)
• ING-CC-0151 Yescarta (axicabtagene ciloleucel)

 

Revised clinical criteria effective June 20, 2022

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

• ING-CC-0045 Increlex (mecasermin)
• ING-CC-0057 Krystexxa (pegloticase)
• ING-CC-0069 Egrifta (tesamorelin)
• ING-CC-0098 Doxorubicin Liposome (Doxil, Lipodox)
• ING-CC-0105 Vectibix (panitumumab)
• ING-CC-0111 Nplate (romiplostim)
• ING-CC-0114 Jevtana (cabazitaxel)
• ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
• ING-CC-0128 Tecentriq (atezolizumab)
• ING-CC-0134 Provenge (sipuleucel-T)
• ING-CC-0137 Cablivi (caplacizumab-yhdp)
• ING-CC-0142 Somatuline Depot (lanreotide)
• ING-CC-0160 Vyepti (eptinezumab)
• ING-CC-0161 Sarclisa (isatuximab-irfc)
• ING-CC-0162 Tepezza (teprotumumab-trbw)
• ING-CC-0165 Trodelvy (sacituzumab govitecan)
• ING-CC-0166 Trastuzumab Agents
• ING-CC-0169 Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
• ING-CC-0178 Synribo (omacetaxine mepesuccinate)
• ING-CC-0188 Imcivree (setmelanotide)
• ING-CC-0192 Cosela (trilaciclib)
• ING-CC-0199 Empaveli (pegcetacoplan)

 

Revised clinical criteria effective July 1, 2022

The following clinical criteria were updated with new procedure and/or diagnosis codes:

• ING-CC-0003 Immunoglobulins
• ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
• ING-CC-0205 Fyarro (sirolimus albumin bound)
• ING-CC-0207 Vyvgart (efgartigimod alfa-fcab)
• ING-CC-0209 Leqvio (inclisiran)
• ING-CC-0210 Enjaymo (sutimlimab-jome)
• ING-CC-0211 Kimmtrak (tebentafusp-tebn)
• ING-CC-0212 Tezspire (tezepelumab-ekko)
• ING-CC-0214 Carvykti (ciltacabtagene autoleucel)

 

Revised clinical criteria effective August 1, 2022

The following clinical criteria was updated with new procedure and/or diagnosis codes:

• ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors

 

New clinical criteria effective November 1, 2022

The following clinical criteria is new:

• ING-CC-0215 Ketamine injection (Ketalar)* 

 

Revised clinical criteria effective November 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-0002 Colony Stimulating Factor Agents* 
• ING-CC-0032 Botulinum Toxin* 
• ING-CC-0068 Growth Hormone* 
• ING-CC-0087 Gamifant (emapalumab-lzsg)* 
• ING-CC-0092 Adcetris (brentuximab vedotin)* 
• ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications* 
• ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)* 
• ING-CC-0119 Yervoy (ipilimumab)* 
• ING-CC-0124 Keytruda (pembrolizumab)* 
• ING-CC-0145 Libtayo (cemiplimab-rwlc)* 
• ING-CC-0153 Adakveo (crizanlizumab)* 
• ING-CC-0175 Proleukin (aldesleukin)* 
• ING-CC-0201 Rybrevant (amivantamab-ymjw)* 

 

The following clinical criteria document was endorsed at the June 23, 2022, clinical criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective November 1, 2022

The following clinical criteria was revised and might result in services that were previously covered but may now be found to be not medically necessary:

• ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors*

 

(ME only per LD 945)

*The applicable policy is attached to this article in PDF format.

 

CTBCBS-CM-003085-22 MEBCBS-CM-003120-22

NHBCBS-CM-003121-22