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)
Summary: On August 19, 2022, and September 9, 2022, 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 to search for specific policies. For questions or 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 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 |
| April 7, 2023 | *ING-CC-0219 | Korsuva (difelikefalin acetate) | New |
| April 7, 2023 | *ING-CC-0220 | Xenpozyme (olipudase alfa) | New |
| April 7, 2023 | *ING-CC-0221 | Spevigo (spesolimab-sbzo) | New |
| April 7, 2023 | ING-CC-0124 | Keytruda (pembrolizumab) | Revised |
| April 7, 2023 | ING-CC-0104 | Levoleucovorin Agents | Revised |
| April 7, 2023 | ING-CC-0100 | Istodax (romidepsin) | Revised |
| April 7, 2023 | ING-CC-0182 | Iron Agents | Revised |
| April 7, 2023 | *ING-CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised |
| April 7, 2023 | *ING-CC-0167 | Rituximab Agents for Oncologic Indications Step Therapy | Revised |
| April 7, 2023 | *ING-CC-0176 | Beleodaq (belinostat) | Revised |
| April 7, 2023 | ING-CC-0180 | Monjuvi (tafasitamab-cxix) | Revised |
| April 7, 2023 | *ING-CC-0107 | Bevacizumab for non-ophthalmologic indications | Revised |
| April 7, 2023 | *ING-CC-0002 | Colony Stimulating Factor Agents | Revised |
| April 7, 2023 | ING-CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised |
| April 7, 2023 | ING-CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
| April 7, 2023 | ING-CC-0216 | Opdualag (nivolumab and relatlimab-rmbw) | Revised |
| April 7, 2023 | ING-CC-0196 | Zynlonta (loncastuximab tesirine-lpyl) | Revised |
| April 7, 2023 | ING-CC-0097 | Vidaza (azacitidine) | Revised |
| April 7, 2023 | *ING-CC-0142 | Somatuline Depot (lanreotide) | Revised |
| April 7, 2023 | *ING-CC-0058 | Byngezia Pen, Sandostatin, or Sandostatin LAR (Octreotide)/ Octreotide Agents | Revised |
| April 7, 2023 | *ING-CC-0082 | Onpattro (patisiran) | Revised |
| April 7, 2023 | *ING-CC-0084 | Tegsedi (inotersen) | Revised |
| April 7, 2023 | *ING-CC-0034 | Hereditary Angioedema Agents | Revised |
| April 7, 2023 | ING-CC-0019 | Zoledronic Acid Agents | Revised |
| April 7, 2023 | *ING-CC-0029 | Dupixent (dupilumab) | Revised |
| April 7, 2023 | *ING-CC-0035 | Duopa (carbidopa and levodopa enteral suspension) | Revised |
| April 7, 2023 | ING-CC-0140 | Zulresso (brexanolone) | Revised |
| April 7, 2023 | ING-CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised |
| April 7, 2023 | ING-CC-0188 | Imcivree (setmelanotide) | Revised |
| April 7, 2023 | *ING-CC-0026 | Testosterone Injectable | Revised |
| April 7, 2023 | *ING-CC-0207 | Vyvgart (efgartigimod alfa-fcab) | Revised |
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Note:
Availity, LLC is an independent company providing administrative support services for Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina.
For mor information, visit Healthy Blue + Medicare.
NCBCBS-CR-014115-22-CPN13242 December 2022