New York
Provider Communications
Medical drug benefit clinical criteria updates – November 2020
Visit clinical criteria to search for specific policies. If you have questions or would like 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 members of 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.
|
Effective date |
Document number |
Clinical Criteria title |
New or revised |
|
March 26, 2021 |
ING-CC-0183* |
Sogroya (somapacitan-beco) |
New |
|
March 26, 2021 |
ING-CC-0148* |
Agents for Hemophilia B |
Revised |
|
March 26, 2021 |
ING-CC-0149* |
Select Clotting Agents for Bleeding Disorders |
Revised |
|
March 26, 2021 |
ING-CC-0065 |
Agents for Hemophilia A and von Willebrand Disease |
Revised |
|
March 26, 2021 |
ING-CC-0125 |
Opdivo (nivolumab) |
Revised |
|
March 26, 2021 |
ING-CC-0119 |
Yervoy (ipilimumab) |
Revised |
|
March 26, 2021 |
ING-CC-0121* |
Gazyva (obinutuzumab) |
Revised |
|
March 26, 2021 |
ING-CC-0048 * |
Spinraza (nusinersen) |
Revised |
|
March 26, 2021 |
ING-CC-0002* |
Colony Stimulating Factor Agents |
Revised |
|
March 26, 2021 |
ING-CC-0034* |
Hereditary Angioedema Agents |
Revised |
|
March 26, 2021 |
ING-CC-0041* |
Complement Inhibitors |
Revised |
|
March 26, 2021 |
ING-CC-0071* |
Entyvio (vedolizumab) |
Revised |
|
March 26, 2021 |
ING-CC-0064* |
Interleukin-1 Inhibitors |
Revised |
|
March 26, 2021 |
ING-CC-0042* |
Monoclonal Antibodies to Interleukin-17 |
Revised |
|
March 26, 2021 |
ING-CC-0066* |
Monoclonal Antibodies to Interleukin-6 |
Revised |
|
March 26, 2021 |
ING-CC-0050* |
Monoclonal Antibodies to Interleukin-23 |
Revised |
|
March 26, 2021 |
ING-CC-0078* |
Orencia (abatacept) |
Revised |
|
March 26, 2021 |
ING-CC-0063* |
Stelara (ustekinumab) |
Revised |
|
March 26, 2021 |
ING-CC-0062* |
Tumor Necrosis Factor Antagonists |
Revised |
|
March 26, 2021 |
ING-CC-0003* |
Immunoglobulins |
Revised |
|
March 26, 2021 |
ING-CC-0039* |
GamaSTAN [immune globulin (human)] |
Revised |
|
March 26, 2021 |
ING-CC-0053 |
Injectable Hydroxyprogesterone for Prevention of Preterm Birth |
Revised |
|
March 26, 2021 |
ING-CC-0073* |
Alpha-1 Proteinase Inhibitor Therapy |
Revised |
|
March 26, 2021 |
ING-CC-0075 |
Rituximab Agents for Non-Oncologic Indications |
Revised |
|
March 26, 2021 |
ING-CC-0072 |
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists |
Revised |
|
March 26, 2021 |
ING-CC-0027* |
Denosumab Agents |
Revised |
|
March 26, 2021 |
ING-CC-0019* |
Zoledronic Acid Agents (Reclast, Zometa) |
Revised |
|
March 26, 2021 |
ING-CC-0011* |
Ocrevus (ocrelizumab) |
Revised |
|
March 26, 2021 |
*ING-CC-0174* |
Kesimpta (ofatumumab) |
Revised |
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