Provider Bulletin March 2021

Clinical Criteria updates

Summary: On June 18, 2020, August 21, 2020, September 24, 2020, and November 20, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Healthy Blue. 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 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

05/25/2021 *ING-CC-0164 Jelmyto (mitomycin gel) New 05/25/2021 *ING-CC-0165 Trodelvy (sacituzumab govitecan) New 05/25/2021 *ING-CC-0166 Trastuzumab Agents Step Therapy New 05/25/2021 *ING-CC-0167 Rituximab Agents for Oncologic Indications Step Therapy New 05/25/2021 *ING-CC-0168 Tecartus (brexucabtagene autoleucel) New 05/25/2021 *ING-CC-0169 Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf) New 05/25/2021 *ING-CC-0170 Uplizna (inebilizumab) New 05/25/2021 *ING-CC-0171 Zepzelca (lurbinectedin) New 05/25/2021 *ING-CC-0172 Viltepso (viltolarsen) New 05/25/2021 *ING-CC-0173 Enspryng (satralizumab-mwge) New 05/25/2021 *ING-CC-0174 Kesimpta (ofatumumab) New 05/25/2021 *ING-CC-0175 Proleukin (aldesleukin) New 05/25/2021 *ING-CC-0176 Beleodaq (belinostat) New 05/25/2021 *ING-CC-0177 Zilretta (triamcinolone acetonide extended-release) New 05/25/2021 *ING-CC-0178 Synribo (omacetaxine mepesuccinate) New 05/25/2021 *ING-CC-0179 Blenrep (belantamab mafodotin-blmf) New 05/25/2021 *ING-CC-0180 Monjuvi (tafasitamab-cxix) New 05/25/2021 *ING-CC-0181 Veklury (remdesivir) New 05/25/2021 *ING-CC-0182 Agents for Iron Deficiency Anemia New 05/25/2021 *ING-CC-0183 Sogroya (somapacitan-beco) New

https://provider.healthybluene.com Healthy Blue is the trade name of Community Care Health Plan of Nebraska, Inc., an independent licensee of the Blue Cross and Blue Shield Association. BNEPEC-0449-21 March 2021 State approval: 01/29/2021