Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the August 19, 2022, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

 

Revised Clinical Criteria effective August 30, 2022

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

• ING-CC-0050 Monoclonal Antibodies to Interleukin-23
• ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
• ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
• ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)

 

Revised Clinical Criteria effective August 30, 2022

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

• ING-CC-0007 Synagis (palivizumab)

 

Revised Clinical Criteria effective September 19, 2022

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

• ING-CC-0029 Dupixent (dupilumab)
• ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
• ING-CC-0100 Istodax (romidepsin)
• ING-CC-0104 Levoleucovorin Agents
• ING-CC-0124 Keytruda (pembrolizumab)
• ING-CC-0140 Zulresso (brexanolone)
• ING-CC-0142 Somatuline Depot (lanreotide)
• ING-CC-0180 Monjuvi (tafasitamab-cxix)
• ING-CC-0182 Iron Agents
• ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
• ING-CC-0188 Imcivree (setmelanotide)
• ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
• ING-CC-0216 Opdualag (nivolumab and relatlimab-rmbw)

 

Revised Clinical Criteria effective September 19, 2022

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-0004 Repository Corticotropin Injection
• ING-CC-0008 Subcutaneous Hormonal Implants
• ING-CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
• ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
• ING-CC-0011 Ocrevus (ocrelizumab)
• ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
• ING-CC-0020 Tysabri (natalizumab)
• ING-CC-0027 Denosumab Agents
• ING-CC-0030 Implantable and ER Buprenorphine Containing Agents
• ING-CC-0036 Naltrexone Implantable Pellets
• ING-CC-0038 Human Parathyroid Hormone Agents
• ING-CC-0044 Exondys 51 (eteplirsen)
• ING-CC-0139 Evenity (romosozumab-aqqg)
• ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)
• ING-CC-0152 Vyondys 53 (golodirsen)
• ING-CC-0156 Reblozyl (luspatercept)
• ING-CC-0171 Zepzelca (lurbinectedin)
• ING-CC-0172 Viltepso (viltolarsen)
• ING-CC-0174 Kesimpta (ofatumumab)
• ING-CC-0179 Blenrep (belantamab mafodotin-blmf)
• ING-CC-0189 Amondys 45 (casimersen)
• ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
• ING-CC-0193 Evkeeza (evinacumab)
• ING-CC-0197 Jemperli (dostarlimab-gxly)
• ING-CC-0200 Aduhelm (aducanumab-avwa)
• ING-CC-0202 Saphnelo (anifrolumab-fnia)
• ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
• ING-CC-0208 Adbry (tralokinumab)
• ING-CC-0209 Leqvio (inclisiran)
• ING-CC-0217 Amvuttra (vutrisiran)

 

Revised Clinical Criteria effective January 1, 2023

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-0028 Benlysta (belimumab)*
• ING-CC-0029 Dupixent (dupilumab)*
• ING-CC-0034 Hereditary Angioedema Agents*
• ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)*
• ING-CC-0050 Monoclonal Antibodies to Interleukin-23*
• ING-CC-0058 Octreotide Agents*
• ING-CC-0075 Rituximab Agents for Non-Oncologic Indications*
• ING-CC-0082 Onpattro (patisiran)*
• ING-CC-0142 Somatuline Depot (lanreotide)*
• ING-CC-0176 Beleodaq (belinostat)*
• ING-CC-0207 Vyvgart (efgartigimod alfa-fcab)*

 

New Clinical Criteria effective January 1, 2023

The following Clinical Criteria is new:

• ING-CC-0219 Korsuva (difelikefalin acetate)*

 

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

 

MEBCBS-CM-006694-22