Clinical criteria updates for specialty pharmacy

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

 

New clinical criteria effective July 6, 2022

The following Clinical Criteria is new:

• ING-CC-0217 Amvuttra (vutrisiran)

 

Revised clinical criteria effective July 25, 2022

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

• ING-CC-0015 Infertility and HCG Agents
• ING-CC-0041 Complement Inhibitors
• ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
• ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
• ING-CC-0119 Yervoy (ipilimumab)
• ING-CC-0125 Opdivo (nivolumab)
• ING-CC-0150 Kymriah (tisagenlecleucel)

 

Revised clinical criteria effective July 25, 2022

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

• ING-CC-0031 Intravitreal Corticosteroid Implants
• ING-CC-0049 Radicava (edaravone)
• ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
• ING-CC-0076 Nulojix (belatacept)
• ING-CC-0077 Palynziq (pegvaliase-pqpz)
• ING-CC-0136 Drug Dosage, Frequency, and Route of Administration
• ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use
• ING-CC-0163 Durysta (bimatoprost implant)
• ING-CC-0208 Adbry (tralokinumab)

 

New clinical criteria effective December 1, 2022

The following Clinical Criteria is new:

• ING-CC-0218 Xipere (triamcinolone acetonide injectable suspension) *

 

Revised clinical criteria effective December 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-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications*

 

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

 

MEBCBS-CM-004802-22