The following clinical criteria documents were endorsed at the September 24, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised clinical criteria effective September 30, 2020

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

  • ING-CC-0063: Stelara (ustekinumab)
  • ING-CC-0086: Spravato (esketamine) Nasal Spray
  • ING-CC-0128: Tecentriq (atezolizumab)

 

New clinical criteria effective September 30, 2020

(The following clinical criteria are new.)

  • ING-CC-0179: Blenrep (belantamab mafodotin-blmf)
  • ING-CC-0180: Monjuvi (tafasitamab-cxix)

 

Revised clinical criteria effective October 26, 2020

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

  • ING-CC-0081: Crysvita (burosumab-twza)

 

Reviewed clinical criteria effective October 26, 2020

(The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.)

  • ING-CC-0008: Subcutaneous Hormonal Implants
  • ING-CC-0012: Brineura (cerliponase alfa)
  • ING-CC-0013: Mepsevii (vestronidase alfa)
  • ING-CC-0017: Xiaflex (collagenase clostridium histolyticum)
  • ING-CC-0018: Lumizyme (alglucosidase alfa)
  • ING-CC-0028: Benlysta (belimumab)
  • ING-CC-0046: Zinplava (bezlotoxumab)
  • ING-CC-0062: Tumor Necrosis Factor Antagonists

 

Revised clinical criteria effective February 1, 2021

(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-0011: Ocrevus (ocrelizumab)
  • ING-CC-0014: Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
  • ING-CC-0021: Fabrazyme (agalsidase beta)
  • ING-CC-0022: Vimizim (elosulfase alfa)
  • ING-CC-0023: Naglazyme (galsulfase)
  • ING-CC-0024: Elaprase (idursufase)
  • ING-CC-0025: Aldurazyme (laronidase)
  • ING-CC-0086: Spravato (esketamine) Nasal Spray
  • ING-CC-0160: Vyepti (eptinezumab-jjmr)

 

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Featured In:
November 2020 Anthem New Hampshire Provider News