Clinical Criteria Updates Notification June 2021
Please note, this communication applies to Healthy Blue + Medicare℠ (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina.
Summary: On August 21, 2020, November 20, 2020, and June 24, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Insert plan. 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 need 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 members of 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.
| Effective date | Document number | Clinical Criteria title | New or revised |
| December 20, 2021 | *ING-CC-0201 | Rybrevant (amivantamab-vmjm) | New |
| December 20, 2021 | *ING-CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised |
| December 20, 2021 | *ING-CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
| December 20, 2021 | ING-CC-0125 | Opdivo (nivolumab) | Revised |
| December 20, 2021 | ING-CC-0124 | Keytruda (pembrolizumab) | Revised |
| December 20, 2021 | *ING-CC-0102 | GnRH Analogs for Oncologic Indications | Revised |
| December 20, 2021 | ING-CC-0076 | Nulojix (belatacept) | Revised |
| December 20, 2021 | *ING-CC-0077 | Palynziq (pegvaliase-pqpz) | Revised |
| December 20, 2021 | ING-CC-0067 | Prostacyclin Infusion and Inhalation Therapy | Revised |
| December 20, 2021 | ING-CC-0194 | Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection | Revised |
For more information, visit Healthy Blue + Medicare
BNCCARE-0200-21 September 2021