| Medical Guidelines |
Reason for Update |
| Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy |
Added HCPCS code J1426 to dosing reference table effective 10/1/2021, deleted C9075, J3490, and J3590 termed 9/30/2021. |
| Belimumab (Benlysta®) |
Added Site of Care medical necessity criteria. |
| Burosumab-twza (Crysvita®) |
Added Site of Care medical necessity criteria. |
| Canakinumab (Ilaris®) |
Added Site of Care medical necessity criteria. |
| CAR-T Therapy |
For Breyanzi: Added HCPCS code Q2054 and description to dosing reference section effective 10/1/2021, deleted C9076, J3490, J3590, and J9999 termed 9/30/2021. For Abecma: Added HCPCS code C9081 to dosing reference table effective 10/1/2021, deleted C9399 termed 9/30/2021. |
| Certolizumab pegol (Cimzia®) |
Added Site of Care medical necessity criteria. |
| Crizanlizumab (Adakveo®) |
Added Site of Care medical necessity criteria. |
| Dostarlimab-gxly (Jemperli®) |
Added HCPCS code C9082 to dosing reference table effective 10/1/2021, deleted C9399 termed 9/30/2021. Removed requirement of medical record documentation for diagnosis. |
| Eculizumab (Soliris®) |
Changed requirement for trial and failure of both ravulizumab (Ultomiris) AND pegcetacoplan (Empaveli) for PNH indication. |
| Eptinezumab-jjmr (Vyepti™) |
Added Site of Care medical necessity criteria. |
| Evinacumab-dgnb (Evkeeza™) |
Added Site of Care medical necessity criteria. Added HCPCS code J1305 to dosing reference table and updated units per code definition effective 10/1/2021, deleted C9079, J3490, and J3590 termed 9/30/2021. |
| Fosdenopterin (Nulibry™) |
Added Site of Care medical necessity criteria. |
| Givosiran (Givlaari®) |
Added Site of Care medical necessity criteria. |
| Guselkumab (Tremfya®) |
Added Site of Care medical necessity criteria. |
| Ibalizumab-uiyk (Trogarzo®) |
Added Site of Care medical necessity criteria. |
| Inebilizumab-cdon (Uplizna™) |
Added Site of Care medical necessity criteria. |
| Intravenous Iron Replacement Therapy |
Original medical policy criteria issued. Changed trial and failure requirement from all preferred products (Ferrlecit, Venofer, and Infed) to one preferred product (Ferrlecit, Venofer, or Infed). |
| Letermovir (Prevymis™) |
Added Site of Care medical necessity criteria. |
| Loncastuximab tesirine-lpyl (Zynlonta™) |
Added HCPCS code C9084 to dosing reference table effective 10/1/2021, deleted C9399 termed 9/30/2021. Removed requirement of documentation of planned dosage. |
| Lumasiran (Oxlumo™) |
Added Site of Care medical necessity criteria. |
| Luspatercept-aamt (Reblozyl®) |
Added Site of Care medical necessity criteria. |
| Melphalan Flufenamide (Pepaxto®) |
Added HCPCS code J9247 to Billing/Coding section effective 10/1/2021, deleted codes C9080, J3490, J3590, J9999 termed 9/30/2021. |
| Ocular Angiogenesis Inhibitor Agents |
Original medical policy criteria issued. Added criteria for patients currently being treated with and stable on therapy with the requested agent for at least 180 days, or at risk if therapy is changed. |
| Patisiran (Onpattro®) |
Added Site of Care medical necessity criteria. |
| Place of Service for Medical Infusions |
Expanded policy to include the following restricted products: Benlysta, Crysvita, Ilaris, Cimzia, Adakveo, Vyepti, Evkeeza, Nulibry, Givlaari, Tremfya, Trogarzo, Uplizna, Prevymis, Oxlumo, Reblozyl, Onpattro, Ryplazim, Empaveli, NPlate, Evenity, Somatostatin Analogs, Tepezza, Ilumya, Stelara; added associated HCPCS/CPT codes: J0490, J0584, J0638, J0717, J0791, J3032, C9079, C9399, J3490, J3590, J0223, J1628, J1746, J1823, J0224, J0896, J0222, J2796, J3111, J2354, J2353, J2502, J1930, J3241, J3245, J3357, J3358. Corrected restricted products and codes for clarity to include: Asceniv, Fasenra, Radicava, and Ultomiris with associated codes J1554, J0517, J1301, and J1303; medical policy formatting change. |
| Pulmonary Hypertension, Drug Management |
Requests for brand Remodulin require a trial and failure of generic treprostinil sodium. |
| Rituximab for the Treatment of Rheumatoid Arthritis |
Added the following applicable diagnosis codes to policy effective 10/1/2021: M45.A0, M45.A1, M45.A2, M45.A3, M45.A4, M45.A5, M45.A6, M45.A7, M45.A8, and M45.AB. |
| Romiplostim (NPlate®) |
Added Site of Care medical necessity criteria. |
| Romosozumab-aqqg (Evenity™) |
Added Site of Care medical necessity criteria. |
| Somatostatin Analogs |
Added Site of Care medical necessity criteria. |
| Teprotumumab-trbw (Tepezza™) |
Added Site of Care medical necessity criteria. |
| Tildrakizumab-asmn (Ilumya®) |
Added Site of Care medical necessity criteria. |
| Trilaciclib (Cosela™) |
Added HCPCS code J1448 to Billing/Coding section effective 10/1/2021, deleted codes C9078, J3490, J3590, J9999 termed 9/30/2021. |
| Ustekinumab (Stelara®) |
Added Site of Care medical necessity criteria. |
| Vedolizumab (Entyvio®) |
Added quantity limit exception criteria. |
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