Clinical criteria updates for specialty pharmacy

The following clinical criteria will be effective May 1, 2019.

 

Erythropoiesis Stimulating Agents ING-CC-0001

Clinical criteria ING-CC-0001 addresses the use of recombinant erythropoietin products, also known as erythropoiesis stimulating agents (ESAs), for the treatment of severe anemia in chronic kidney disease (CKD), HIV, cancer, surgery, and other conditions.

 

Effective for dates of service on and after May 1, 2019, the use of Procrit®, Epogen®, and Retacrit™ for the treatment of severe anemia in hepatitis C, chronic inflammatory disease, and bone marrow transplant are considered not medically necessary. 

 

H.P. Acthar Gel® (repository corticotropin injection) ING-CC-0004

Clinical criteria ING-CC-0004 addresses the use of repository corticotropin injection for the treatment of infantile spasms (West syndrome) and adults with a corticosteroid-responsive condition, including but not limited to acute exacerbations of multiple sclerosis.

 

Effective for dates of service on and after May 1, 2019, repository corticotropin injections for the treatment of conditions other than infantile spasms (West syndrome) are considered not medically necessary. 

 

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

Clinical criteria ING-CC-0072 addresses the use of intravitreal vascular endothelial growth factor (VEGF) antagonists for the treatment of diabetic retinopathy and other retinal disorders associated with neovascularization.

 

Effective for dates of service on and after May 1, 2019, the use of Eylea® for the treatment of radiation retinopathy is considered not medically necessary. 

 

To access the clinical criteria information please click here.