Clinical Criteria Updates (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 December 22, 2022, May 2, 2023, and May 19, 2023, the Pharmacy and Therapeutic (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 on Anthem.com to search for specific policies. If you have questions or need additional information, email Carelon Healthcare Services.
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.
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 | Clinical Criteria number | Clinical Criteria title | New or revised |
| November 1, 2023 | *CC-0237 | Qalsody (tofersen) | New |
| November 1, 2023 | *CC-0238 | Hydroxyprogesterone caproate | New |
| November 1, 2023 | *CC-0240 | Zynyz (retifanlimab-dlwr) | New |
| November 1, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
| November 1, 2023 | CC-0002 | Colony Stimulating Factor Agents | Revised |
| November 1, 2023 | CC-0128 | Tecentriq (atezolizumab) | Revised |
| November 1, 2023 | CC-0098 | Doxorubicin Liposome (Doxil, Lipodox) | Revised |
| November 1, 2023 | CC-0101 | Torisel (temsirolimus) | Revised |
| November 1, 2023 | CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
| November 1, 2023 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
| November 1, 2023 | CC-0092 | Adcetris (brentuximab vedotin) | Revised |
| November 1, 2023 | CC-0095 | Velcade (bortezomib) | Revised |
| November 1, 2023 | CC-0105 | Vectibix (panitumumab) | Revised |
| November 1, 2023 | CC-0178 | Synribo (omacetaxine mepesuccinate) | Revised |
| November 1, 2023 | CC-0114 | Jevtana (cabazitaxel) | Revised |
| November 1, 2023 | CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
| November 1, 2023 | *CC-0032 | Botulinum Toxin | Revised |
| November 1, 2023 | CC-0068 | Growth Hormone | Revised |
| November 1, 2023 | *CC-0057 | Krystexxa (pegloticase) | Revised |
| November 1, 2023 | *CC-0125 | Opdivo (nivolumab) | Revised |
| November 1, 2023 | *CC-0225 | Tzield (teplizumab-mzwv) | Revised |
| November 1, 2023 | *CC-0124 | Keytruda (pembrolizumab) | Revised |
Healthy Blue + Medicare HMO D-SNP
Blue Cross and Blue Shield of North Carolina Senior Health, DBA Blue Cross and Blue Shield of North Carolina, is an HMO D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.
NCBCBS-CR-031954-23-CPN30755 July 2023