Medicare 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
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