Clinical criteria updates for specialty pharmacy

The following clinical criteria documents were endorsed at the December 20, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center. 

 

New clinical criteria effective December 24, 2019

The following clinical criteria is new and has been adopted.

• ING-CC-0152 - Vyondys 53 (golodirsen)

 

New clinical criteria effective January 20, 2020

The following clinical criteria are new and have been adopted.

• ING-CC-0153 - Adakveo (crizanlizumab)
• ING-CC-0154 - Givlaari (givosiran)

 

Revised clinical criteria effective January 20, 2020

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

• ING-CC-0032 - Botulinum Toxin
• ING-CC-0099 - Abraxane (paclitaxel, protein bound)
• ING-CC-0128 - Tecentriq (atezolizumab)

 

Revised clinical criteria effective June 1, 2020

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-0004 - H.P. Acthar Gel (repository corticotropin injection)
• ING-CC-0027 - Denosumab Agents