Medical Drug Benefit Clinical Criteria Updates (Healthy Blue + MedicareSM HMO-DSNP)
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 May 20, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the 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. If you have questions or would like additional information, send an inquiry to 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. This notice is meant to inform the provider of new or revised criteria that has been adopted by Blue Cross NC only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
| Effective date | Document number | Clinical Criteria title | New or revised |
| December 30 2022 | *ING-CC-0200 | Aduhelm | New |
| December 30 2022 | *ING-CC-0215 | Ketamine injection (Ketalar) | New |
| December 30 2022 | *ING-CC-0216 | Opdualag (nivolumab and relatlimab-rmbw) | New |
| December 30 2022 | *ING-CC-0153 | Adakveo (crizanlizumab) | Revised |
| December 30 2022 | *ING-CC-0002 | Colony Stimulating Factor Agents | Revised |
| December 30 2022 | *ING-CC-0124 | Keytruda (pembrolizumab) | Revised |
| December 30 2022 | ING-CC-0101 | Torisel (temsirolimus) | Revised |
| December 30 2022 | *ING-CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
| December 30 2022 | ING-CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
| December 30 2022 | *ING-CC-0092 | Adcetris (brentuximab vedotin) | Revised |
| December 30 2022 | ING-CC-0106 | Erbitux (cetuximab) | Revised |
| December 30 2022 | *ING-CC-0175 | Proleukin (aldesleukin) | Revised |
| December 30 2022 | ING-CC-0116 | Bendamustine agents | Revised |
| December 30 2022 | *ING-CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
| December 30 2022 | ING-CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised |
| December 30 2022 | *ING-CC-0032 | Botulinum Toxin | Revised |
| December 30 2022 | *ING-CC-0052 | Dihydroergotamine (DHE) injection | Revised |
| December 30 2022 | *ING-CC-0068 | Growth Hormone | Revised |
| December 30 2022 | *ING-CC-0087 | Gamifant (emapalumab) | Revised |
| December 30 2022 | ING-CC-0194 | Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection | Revised |
| December 30 2022 | ING-CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised |
| December 30 2022 | *ING-CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
| December 30 2022 | *ING-CC-0201 | Rybrevant (amivantamab-ymjw) | Revised |
| December 30 2022 | *ING-CC-0119 | Yervoy (ipilimumab) | Revised |