The following clinical criteria documents were endorsed at the February 21, 2020 clinical criteria meeting. To access the clinical criteria information please click here.

 

Revised clinical criteria effective March 3, 2020

(The following criteria was reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)

  • ING-CC-0140: Zulresso (brexanolone)

 

Revised clinical criteria effective March 23, 2020

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

  • ING-CC-0002: Colony Stimulating Factor Agents
  • ING-CC-0090: Ixempra (ixabepilone)
  • ING-CC-0091: Lartruvo (olaratumab)
  • ING-CC-0094: Alimta (pemetrexed disodium)
  • ING-CC-0119: Yervoy (ipilimumab)
  • ING-CC-0121 Gazyva (obinutuzumab)
  • ING-CC-0123: Cyramza (ramucirumab)
  • ING-CC-0124: Keytruda (pembrolizumab)
  • ING-CC-0125: Opdivo (nivolumab)
  • ING-CC-0130: Imfinzi (durvalumab)
  • ING-CC-0131: Besponsa (inotuzumab ozogamicin)

 

Revised clinical criteria effective March 23, 2020

(The following criteria were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)

  • ING-CC-0044: Eteplirsen (Exondys 51®)
  • ING-CC-0067: Prostacyclin Infusion and Inhalation Therapy
  • ING-CC-0072: Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
  • ING-CC-0075: Rituximab Agents for Non-Oncology Indications
  • ING-CC-0085: Actimmune (interferon gamma-1B)
  • ING-CC-0086: Spravato (esketamine) Nasal Spray
  • ING-CC-0088: Elzonris (tagraxofusp-erzs)
  • ING-CC-0089: Mozobil
  • ING-CC-0096: Asparagine Specific Enzymes: Oncaspar (pegaspargase), Erwinaze (asparaginase [erwinia chrysanthemi])
  • ING-CC-0103: Faslodex (fulvestrant)
  • ING-CC-0108: Halaven (eribulin)
  • ING-CC-0110: Perjeta (pertuzumab)
  • ING-CC-0113: Sylvant (siltuximab)
  • ING-CC-0115: Kadcyla (ado-trastuzumab)
  • ING-CC-0117: Empliciti (elotuzumab)
  • ING-CC-0120: Kyprolis (carfilzomib)
  • ING-CC-0122: Arzerra (ofatumumab)
  • ING-CC-0126: Blincyto (blinatumomab)
  • ING-CC-0129: Bavencio (avelumab)
  • ING-CC-0132: Mylotarg (gemtuzumab ozogamicin)
  • ING-CC-0152: Vyondys 53 (golodirsen)

 

Archived clinical criteria effective March 23, 2020

  • ING-CC-0138: Asparlas (calaspargase pegol-mknl)  

 

Revised clinical criteria effective July 1, 2020

(The following criteria listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)

  • ING-CC-0078: Orencia (abatacept)

 

New clinical criteria effective August 1, 2020

(The criteria below is new and may result in services previously covered now being considered either not medically necessary and/or investigational.)

  • ING-CC-0155: Ethyol (amifostine)
  • ING-CC-0156: Reblozyl (luspatercept)
  • ING-CC-0157: Padcev (enfortumab vedotin)
  • ING-CC-0158: Enhertu (fam-trastuzumab deruxtecan-nxki)
  • ING-CC-0159: Scenesse (afamelanotide)
  • ING-CC-0160: Vyepti (eptinezumab-jjmr)

 

Revised clinical criteria effective August 1, 2020

(The following criteria listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)

  • ING-CC-0002: Colony Stimulating Factor Agents
  • ING-CC-0015: Infertility and HCG Agents
  • ING-CC-0033: Xolair (omalizumab)
  • ING-CC-0038: Human Parathyroid Hormone Agents
  • ING-CC-0043: Monoclonal Antibodies to Interleukin-5
  • ING-CC-0049: Radicava (edaravone)
  • ING-CC-0062: Tumor Necrosis Factor Antagonists
  • ING-CC-0088: Elzonris (tagraxofusp-erzs)
  • ING-CC-0094: Alimta (pemetrexed disodium)
  • ING-CC-0099: Abraxane (paclitaxel, protein bound)
  • ING-CC-0109: Zaltrap (ziv-aflibercept)
  • ING-CC-0112: Xofigo (Radium Ra 223 Dichloride)
  • ING-CC-0118: Radioimmunotherapy: Zevalin; azedra; Lutathera
  • ING-CC-0119: Yervoy (ipilimumab)
  • ING-CC-0123: Cyramza (ramucirumab)
  • ING-CC-0125: Opdivo (nivolumab)
  • ING-CC-0135: Melanoma Vaccines

 

419-0520-PN-NE



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May 2020 Anthem New Hampshire Provider News