Clinical Criteria Updates for Healthy Blue + Medicare℠ (HMO D-SNP)
Please note, this communication applies to Healthy Blue + Medicare℠ (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
On November 19, 2021, December 13, 2021, and January 10, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the Healthy Blue + Medicare medical drug benefit for Blue Cross NC. These policies were developed, revised, or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. For questions or additional information, email druglist@ingenio-rx.com.
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.
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 |
| July 12, 2022 | *ING-CC-0205 | Fyarro (sirolimus albumin bound) | New |
| July 12, 2022 | *ING-CC-0206 | Besremi (ropeginterferon alfa-2b-njft) | New |
| July 12, 2022 | *ING-CC-0207 | Vyvgart (efgartigimod alfa-fcab) | New |
| July 12, 2022 | *ING-CC-0208 | Adbry (tralokinumab) | New |
| July 12, 2022 | *ING-CC-0209 | Leqvio (inclisiran) | New |
| July 12, 2022 | ING-CC-0124 | Keytruda (pembrolizumab) | Revised |
| July 12, 2022 | ING-CC-0079 | Strensiq (Asfotase Alfa) | Revised |
| July 12, 2022 | ING-CC-0015 | Infertility and HCG Agents | Revised |
| July 12, 2022 | ING-CC-0102 | Gonadotropin releasing hormone (GNRH) Analogs for Oncologic Indications | Revised |
| July 12, 2022 | ING-CC-0168 | Tecartus (brexucabtagene autoleucel) | Revised |
| July 12, 2022 | ING-CC-0029 | Dupixent (dupilumab) | Revised |
| July 12, 2022 | *ING-CC-0004 | Repository Corticotropin Injection | Revised |
| July 12, 2022 | ING-CC-0072 | Selective Vascular Endothelial Growth Factor (VEGF) Antagonists | Revised |
For more information, visit Healthy Blue + Medicare.
BNCCARE-0667-22 April 2022