| Policy Name |
Revised Criteria |
| Aducanumab-avwa (Aduhelm™) |
Added HCPCS code J0172 to dosing reference table effective 1/1/2022, deleted C9399, J3490, and J3590 termed 12/31/2021. Blue Cross NC Pharmacy and Therapeutics Committee 6/29/2021. |
| Anifrolumab-fnia (Saphnelo™) |
Added HCPCS code C9086 to dosing reference table effective 1/1/2022, deleted C9399 termed 12/31/2021. Blue Cross NC Pharmacy and Therapeutics Committee 12/21/2021. |
| CAR-T Therapy |
Added HCPCS code Q2055 and description to dosing reference section for Abecma effective 1/1/2022, deleted C9081, J3490, J3590, and J9999 termed 12/31/2021. Blue Cross NC Pharmacy and Therapeutics Committee 6/29/2021. |
| Dostarlimab-gxly (Jemperli®) |
Added HCPCS code J9272 to dosing reference table effective 1/1/2022, deleted C9082, J3490, J3590, and J9999 termed 12/31/2021. Blue Cross NC Pharmacy and Therapeutics Committee 12/21/2021. |
| Enzyme Replacement Therapy (ERT) for Lysosomal Storage Disorders |
Added HCPCS code C9085 to dosing reference table for Nexviazyme effective 1/1/2022, deleted C9399 termed 12/31/2021. Blue Cross NC Pharmacy and Therapeutics Committee 12/21/2021. |
| White Blood Cell Growth Factors |
Added HCPCS code J2506 to Billing/Coding section effective 1/1/2022, J2505 to be termed 12/31/2021. |
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