Products & Programs PharmacyCommercialMay 1, 2023

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the February 24, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective August 1, 2023

The following Clinical Criteria are new:

  • CC-0230 Adstiladrin (nadofaragene firadenovec-vncg)
  • CC-0233 Rebyota (fecal microbiota, live – jslm)

Revised Clinical Criteria effective August 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-0062 Tumor Necrosis Factor Antagonists
  • CC-0086 Spravato (esketamine) Nasal Spray
  • CC-0096 Asparagine Specific Enzymes
  • CC-0110 Perjeta (pertuzumab)
  • CC-0115 Kadcyla (ado-trastuzumab)
  • CC-0116 Bendamustine agents
  • CC-0119 Yervoy (ipilimumab)
  • CC-0120 Kyprolis (carfilzomib)
  • CC-0128 Tecentriq (atezolizumab)
  • CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)

MULTI-BCBS-CM-022636-23

PUBLICATIONS: May 2023 Provider News