Medical Policy Updates

Home ❯ Providers ❯ Medical Policies and Coverage ❯ Back to Medical Policy Updates ❯ Notification of Policy Revisions Effective October 1, 2021 (Posted August 2, 2021)

Notification of Policy Revisions Effective October 1, 2021 (Posted August 2, 2021)

Medical Policy Revision
Belimumab (Benlysta®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Burosumab-twza (Crysvita®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Canakinumab (Ilaris®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Certolizumab pegol (Cimzia®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Crizanlizumab (Adakveo®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Eculizumab (Soliris®) “Notification” Changed requirement for trial and failure of both ravulizumab (Ultomiris) AND pegcetacoplan (Empaveli) for PNH indication. Policy notification given 8/2/2021 for effective date 10/1/2021.
Eptinezumab-jjmr (Vyepti™) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Evinacumab-dgnb (Evkeeza™) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Fosdenopterin (Nulibry™) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Givosiran (Givlaari®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Guselkumab (Tremfya®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Ibalizumab-uiyk (Trogarzo®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Inebilizumab-cdon (Uplizna™) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Letermovir (Prevymis™) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Lumasiran (Oxlumo™) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Luspatercept-aamt (Reblozyl®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Patisiran (Onpattro®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Place of Service for Medical Infusions “Notification” 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. Policy notification given 8/2/2021 for effective date 10/1/2021.
Romiplostim (NPlate®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Romosozumab-aqqg (Evenity™) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Somatostatin Analogs “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Teprotumumab-trbw (Tepezza™) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Tildrakizumab-asmn (Ilumya®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Ustekinumab (Stelara®) “Notification” Added Site of Care medical necessity criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.
Vedolizumab (Entyvio®) “Notification” Added quantity limit exception criteria. Policy notification given 8/2/2021 for effective date 10/1/2021.