Clinical Criteria Updates September 2022 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 November 19, 2021, February 25, 2022, August 19, 2022, and September 22, 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, please email druglist@carelon.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 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 |
| May 19, 2023 | *ING-CC-0018 | Pompe Disease | Revised |
| May 19, 2023 | *ING-CC-0017 | Xiaflex (collagenase clostridium histolyticum) | Revised |
| May 19, 2023 | ING-CC-0174 | Kesimpta (ofatumumab) | Revised |
| May 19, 2023 | ING-CC-0089 | Mozobil (plerixafor) | Revised |
| May 19, 2023 | ING-CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised |
| May 19, 2023 | ING-CC-0130 | Imfinzi (durvalumab) | Revised |
| May 19, 2023 | ING-CC-0097 | Vidaza (azacitidine) | Revised |
| May 19, 2023 | *ING-CC-0072 | Vascular Endothelial Growth Factor Inhibitors | Revised |
| May 19, 2023 | ING-CC-0063 | Stelara (ustekinumab) | Revised |
| May 19, 2023 | *ING-CC-0002 | Colony Stimulating Factor Agents | Revised |
| May 19, 2023 | *ING-CC-0107 | Bevacizumab for non-ophthalmologic indications | Revised |
| May 19, 2023 | *ING-CC-0062 | Tumor Necrosis Factor Antagonists | Revised |
| May 19, 2023 | *ING-CC-0003 | Immunoglobulins | Revised |
For more information, visit Healthy Blue + Medicare.
NCBCBS-CR-013905-22 February 2023