Policy UpdatesMedicare AdvantageJuly 10, 2024

Clinical Criteria updates

Effective August 12, 2024

Summary: On May 17, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for BMA. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or for additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: newly published criteria
  • Revised: addition or removal of medical necessity requirements, new document number
  • Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

  • The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by BMA only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date

Clinical Criteria number

Clinical Criteria title

New or revised

August 12, 2024

*CC-0262

Tevimbra (tislelizumab-jsgr)

New

August 12, 2024

*CC-0162

Tepezza (teprotumumab-trbw)

Revised

August 12, 2024

*CC-0111

Nplate (romiplostim)

Revised

August 12, 2024

CC-0165

Trodelvy (sacituzumab govitecan)

Revised

August 12, 2024

*CC-0002

Colony Stimulating Factor Agents

Revised

August 12, 2024

CC-0128

Tecentriq (atezolizumab)

Revised

August 12, 2024

*CC-0098

Doxorubicin Liposome (Doxil, Lipodox)

Revised

August 12, 2024

*CC-0101

Torisel (temsirolimus)

Revised

August 12, 2024

*CC-0107

Bevacizumab for Non-Ophthalmologic Indications

Revised

August 12, 2024

CC-0143

Polivy (polatuzumab vedotin-piiq)

Revised

August 12, 2024

*CC-0092

Adcetris (brentuximab vedotin)

Revised

August 12, 2024

CC-0106

Erbitux (cetuximab)

Revised

August 12, 2024

*CC-0105

Vectibix (panitumumab)

Revised

August 12, 2024

CC-0145

Libtayo (cemiplimab-rwlc)

Revised

August 12, 2024

CC-0160

Vyepti (eptinezumab)

Revised

August 12, 2024

CC-0102

GNRH Analogs for Oncologic Indications

Revised

August 12, 2024

CC-0201

Rybrevant (amivantamab-ymjw)

Revised

August 12, 2024

*CC-0188

Imcivree (setmelanotide)

Revised

August 12, 2024

*CC-0124

Keytruda (pembrolizumab)

Revised

August 12, 2024

CC-0041

Complement C5 Inhibitors

Revised

August 12, 2024

CC-0199

Empaveli (pegcetacoplan)

Revised

August 12, 2024

*CC-0130

Imfinzi (durvalumab)

Revised

August 12, 2024

CC-0240

Zynyz (retifanlimab-dlwr)

Revised

August 12, 2024

CC-0123

Cyramza (ramucirumab)

Revised

August 12, 2024

CC-0187

Breyanzi (lisocabtagene maraleucel)

Revised

August 12, 2024

CC-0158

Enhertu (fam-trastuzumab deruxtecan-nxki)

Revised

August 12, 2024

CC-0226

Elahere (mirvetuximab)

Revised

August 12, 2024

CC-0043

Monoclonal Antibodies to Interleukin-5

Revised

August 12, 2024

*CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

August 12, 2024

CC-0221

Spevigo (spesolimab-sbzo)

Revised

August 12, 2024

CC-0071

Entyvio (vedolizumab)

Revised

August 12, 2024

*CC-0063

Ustekinumab Agents

Revised

Blue Medicare Advantage is the trade name of Group Retiree Health Solutions, Inc., an independent licensee of the Blue Cross Blue Shield Association.

PAIBC-CR-061719-24-CPN61521