Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the November 18, 2022, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective May 1, 2023

The following Clinical Criteria are new:

• CC-0222 Tecvayli (teclistamab-cqyv)*
• CC-0223 Imjudo (tremelimumab-actl)*
• CC-0224 Pedmark (sodium thiosulfate injection)*

Revised Clinical Criteria effective May 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:

• CC-0003 Immunoglobulins*
• CC-0041 Complement Inhibitors*
• CC-0042 Monoclonal Antibodies to Interleukin-17*
• CC-0050 Monoclonal Antibodies to Interleukin-23*
• CC-0062 Tumor Necrosis Factor Antagonists*
• CC-0063 Stelara (ustekinumab)*
• CC-0064 Interleukin-1 Inhibitors*
• CC-0066 Monoclonal Antibodies to Interleukin-6*
• CC-0071 Entyvio (vedolizumab)*
• CC-0078 Orencia (abatacept)*
• CC-0100 Istodax (romidepsin)*
• CC-0107 Bevacizumab for Non-Ophthalmologic Indications*
• CC-0124 Keytruda (pembrolizumab)*
• CC-0150 Kymriah (tisagenlecleucel)*
• CC-0151 Yescarta (axicabtagene ciloleucel)*
• CC-0168 Tecartus (brexucabtagene autoleucel)*
• CC-0187 Breyanzi (lisocabtagene maraleucel)*
• CC-0195 Abecma (idecabtagene vicleucel)*
• CC-0204 Tivdak (tisotumab vedotin-tftv)*
• CC-0205 Fyarro (siroliumus albumin bound)*
• CC-0214 Carvykti (ciltacabtagene autoleucel)*

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