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 February 24, 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 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 |
| July 31, 2023 | *CC-0232 | Lunsumio (mosunetuzumab-axgb) | New |
| July 31, 2023 | *CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | New |
| July 31, 2023 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | New |
| July 31, 2023 | *CC-0234 | Syfovre (pegcetacoplan) | New |
| July 31, 2023 | *CC-0231 | Lamzede (velmanase alfa-tycv) | New |
| July 31, 2023 | CC-0007 | Synagis (palivizumab) | Revised |
| July 31, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised |
| July 31, 2023 | CC-0210 | Enjaymo (sutimlimab-jome) | Revised |
| July 31, 2023 | *CC-0128 | Tecentriq (atezolizumab) | Revised |
| July 31, 2023 | *CC-0116 | Bendamustine agents | Revised |
| July 31, 2023 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised |
| July 31, 2023 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised |
| July 31, 2023 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
| July 31, 2023 | *CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
| July 31, 2023 | CC-0125 | Opdivo (nivolumab) | Revised |
| July 31, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised |
| July 31, 2023 | CC-0099 | Abraxane (paclitaxel, protein bound) | Revised |
| July 31, 2023 | *CC-0093 | Docetaxel (Taxotere) | Revised |
| July 31, 2023 | CC-0094 | Pemetrexed Agents (Alimta, Pemfexy) | Revised |
| July 31, 2023 | CC-0130 | Imfinzi (durvalumab) | Revised |
| July 31, 2023 | CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised |
| July 31, 2023 | CC-0123 | Cyramza (ramucirumab) | Revised |
| July 31, 2023 | CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised |
| July 31, 2023 | CC-0121 | Gazyva (obinutuzumab) | Revised |
| July 31, 2023 | *CC-0096 | Asparagine Specific Enzymes | Revised |
| July 31, 2023 | *CC-0120 | Kyprolis (carfilzomib) | Revised |
| July 31, 2023 | CC-0117 | Empliciti (elotuzumab) | Revised |
| July 31, 2023 | CC-0126 | Blincyto (blinatumomab) | Revised |
| July 31, 2023 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised |
| July 31, 2023 | CC-0097 | Vidaza (azacitidine) | Revised |
| July 31, 2023 | CC-0129 | Bavencio (avelumab) | Revised |
| July 31, 2023 | CC-0090 | Ixempra (ixabepilone) | Revised |
| July 31, 2023 | *CC-0110 | Perjeta (pertuzumab) | Revised |
| July 31, 2023 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised |
| July 31, 2023 | CC-0124 | Keytruda (pembrolizumab) | Revised |
| July 31, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
| July 31, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
For more information, visit Healthy Blue + Medicare.
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-024402-23 May 2023