Medical Drug Benefit Clinical Criteria Updates

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Medicaid Managed Care

Provider Bulletin April 2021 Medical drug benefit Clinical Criteria updates

On August 16, 2019, November 15, 2019, December 18, 2019, February 21, 2020, March 26, 2020, May 15, 2020, 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. 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 (*): 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 06/07/2021 ING-CC-0154* Givlaari (givosiran) New 06/07/2021 ING-CC-0155* Ethyol (amifostine) New 06/07/2021 ING-CC-0156* Reblozyl (luspatercept) New 06/07/2021 ING-CC-0157* Padcev (enfortumab vedotin) New 06/07/2021 ING-CC-0158* Enhertu (fam-trastuzumab deruxtecan-nxki) New 06/07/2021 ING-CC-0159* Scenesse (afamelanotide) New 06/07/2021 ING-CC-0161* Sarclisa (isatuximab-irfc) New 06/07/2021 ING-CC-0162* Tepezza (teprotumumab-trbw) New 06/07/2021 ING-CC-0163* Durysta (bimatoprost implant) New 06/07/2021 ING-CC-0164* Jelmyto (mitomycin gel) New 06/07/2021 ING-CC-0165* Trodelvy (sacituzumab govitecan) New 06/07/2021 ING-CC-0168* Tecartus (brexucabtagene autoleucel) New Phesgo (pertuzumab/trastuzumab/hyaluronidase- 06/07/2021 ING-CC-0169* New zzxf) 06/07/2021 ING-CC-0170* Uplizna (inebilizumab) New 06/07/2021 ING-CC-0171* Zepzelca (lurbinectedin) New 06/07/2021 ING-CC-0172* Viltepso (viltolarsen) New 06/07/2021 ING-CC-0173* Enspryng (satralizumab-mwge) New 06/07/2021 ING-CC-0175* Proleukin (aldesleukin) New 06/07/2021 ING-CC-0176* Beleodaq (belinostat) New 06/07/2021 ING-CC-0177* Zilretta (triamcinolone acetonide extended-release) New

https://providers.healthybluela.com Healthy Blue is the trade name of Community Care Health Plan of Louisiana, Inc., an independent licensee of the Blue Cross an d Blue Shield Association. BLA-NL-0292-21 April 2021 Healthy Blue Medicaid Managed Care Medical drug benefit Clinical Criteria updates Page 2 of 3

Effective date Document number Clinical Criteria title New or revised 06/07/2021 ING-CC-0178* Synribo (omacetaxine mepesuccinate) New 06/07/2021 ING-CC-0179* Blenrep (belantamab mafodotin-blmf) New 06/07/2021 ING-CC-0181* Veklury (remdesivir) New 06/07/2021 ING-CC-0183* Sogroya (somapacitan-beco) New Lemtrada (alemtuzumab) for the Treatment of 06/07/2021 ING-CC-0009* Revised Multiple Sclerosis 06/07/2021 ING-CC-0017* Xiaflex (collagenase clostridium histolyticum) Revised 06/07/2021 ING-CC-0027* Denosumab Agents Revised 06/07/2021 ING-CC-0029* Dupixent (dupilumab) Revised 06/07/2021 ING-CC-0031* Intravitreal Corticosteroid Implants Revised 06/07/2021 ING-CC-0032* Botulinum Toxin Revised Duopa (carbidopa and levodopa enteral 06/07/2021 ING-CC-0035* Revised suspension) 06/07/2021 ING-CC-0038* Human Parathyroid Hormone Agents Revised 06/07/2021 ING-CC-0039* GamaSTAN [immune globulin (human)] Revised 06/07/2021 ING-CC-0042* Monoclonal Antibodies to Interleukin-17 Revised 06/07/2021 ING-CC-0049* Radicava (edaravone) Revised 06/07/2021 ING-CC-0050* Monoclonal Antibodies to Interleukin-23 Revised Enzyme Replacement Therapy for Gaucher 06/07/2021 ING-CC-0051* Revised Disease 06/07/2021 ING-CC-0057* Krystexxa (pegloticase) Revised Octreotide Agents (Byngezia Pen, Sandostatin, or 06/07/2021 ING-CC-0058* Revised Sandostatin LAR) 06/07/2021 ING-CC-0061* GnRH Analogs for the Treatment of Non- Revised Oncologic Indications 06/07/2021 ING-CC-0063* Stelara (ustekinumab) Revised 06/07/2021 ING-CC-0064* Interleukin-1 Inhibitors Revised 06/07/2021 ING-CC-0066* Monoclonal Antibodies to Interleukin-6 Revised 06/07/2021 ING-CC-0071* Entyvio (vedolizumab) Revised 06/07/2021 ING-CC-0073* Alpha-1 Proteinase Inhibitor Therapy Revised 06/07/2021 ING-CC-0082* Onpattro (patisiran) Revised 06/07/2021 ING-CC-0084* Tegsedi (inotersen) Revised 06/07/2021 ING-CC-0088* Elzonris (tagraxofusp-erzs) Revised 06/07/2021 ING-CC-0094* Alimta (pemetrexed disodium) Revised 06/07/2021 ING-CC-0096* Asparagine Specific Enzymes Revised 06/07/2021 ING-CC-0098* Doxorubicin Liposome (Doxil, Lipodox) Revised 06/07/2021 ING-CC-0099* Abraxane (paclitaxel, protein bound) Revised 06/07/2021 ING-CC-0101* Torisel (temsirolimus) Revised 06/07/2021 ING-CC-0105* Vectibix (panitumumab) Revised 06/07/2021 ING-CC-0106* Erbitux (cetuximab) Revised 06/07/2021 ING-CC-0109* Zaltrap (ziv-aflibercept) Revised 06/07/2021 ING-CC-0112* Xofigo (Radium Ra 223 Dichloride) Revised Healthy Blue Medicaid Managed Care Medical drug benefit Clinical Criteria updates Page 3 of 3

Effective date Document number Clinical Criteria title New or revised Radioimmunotherapy and Somatostatin Receptor 06/07/2021 ING-CC-0118* Targeted Radiotherapy (Azedra, Lutathera, Revised Zevalin) 06/07/2021 ING-CC-0119* Yervoy (ipilimumab) Revised 06/07/2021 ING-CC-0121* Gazyva (obinutuzumab) Revised 06/07/2021 ING-CC-0123* Cyramza (ramucirumab) Revised 06/07/2021 ING-CC-0124* Keytruda (pembrolizumab) Revised 06/07/2021 ING-CC-0125* Opdivo (nivolumab) Revised 06/07/2021 ING-CC-0128* Tecentriq (atezolizumab) Revised 06/07/2021 ING-CC-0134* Provenge (sipuleucel-T) Revised 06/07/2021 ING-CC-0135* Melanoma Vaccines Revised 06/07/2021 ING-CC-0150* Kymriah (tisagenlecleucel) Revised 06/07/2021 ING-CC-0153* Adakveo (crizanlizumab) Revised