The following clinical criteria documents were endorsed at the March 15, 2021, Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

New clinical criteria effective March 31, 2021

The following clinical criteria are new.

  • ING-CC-0191: Pepaxto (melphalan flufenamide; melflufen)
  • ING-CC-0192: Cosela (trilaciclib)

 

Revised clinical criteria effective March 31, 2021

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

  • ING-CC-0177: Zilretta (triamcinolone acetonide extended-release)

 

New clinical criteria effective April 13, 2021

The following clinical criteria is new.

  • ING-CC-0195: Abecma (idecabtagene vicleucel)

 

Revised clinical criteria effective April 26, 2021

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

  • ING-CC-0064: Interleukin-1 Inhibitors
  • ING-CC-0075: Rituxan (rituximab) for Non-Oncologic Indications
  • ING-CC-0125: Opdivo (nivolumab)
  • ING-CC-0127: Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
  • ING-CC-0145: Libtayo (cemiplimab-rwlc)
  • ING-CC-0151: Yescarta (axicabtagene ciloleucel)

 

Reviewed clinical criteria effective April 26, 2021

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

  • ING-CC-0011: Ocrevus (ocrelizumab)
  • ING-CC-0034: Hereditary Angioedema Agents
  • ING-CC-0037: Kanuma (sebelipase alfa)
  • ING-CC-0070: Jetrea (ocriplasmin)
  • ING-CC-0087: Gamifant (emapalumab-lzsg)
  • ING-CC-0160: Vyepti (eptinezumab)
  • ING-CC-0182: Agents for Iron Deficiency Anemia

 

Revised clinical criteria effective May 1, 2021

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

  • ING-CC-0072: Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

 

New clinical criteria effective August 1, 2021

The following clinical criteria are new.

  • ING-CC-0193: Evkeeza (evinacumab)
  • ING-CC-0194: Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

 

Revised clinical criteria effective August 1, 2021

The following current 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-0130: Imfinzi (durvalumab)
  • ING-CC-0145: Libtayo (cemiplimab-rwlc)
  • ING-CC-0159: Scenesse (afamelanotide)

 

1130-0521-PN-NE



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May 2021 Anthem New Hampshire Provider News