Welcome to the Clinical Criteria Page
This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. The effective dates for using these documents for clinical reviews are communicated through the Provider notification process. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the traditional process.
The clinical criteria information is alphabetized in the table below.
Development of clinical criteria
All clinical criteria are developed to help guide clinically appropriate use of drugs and therapies and are reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is an independent and external committee including practicing physicians, pharmacists, and clinicians from leading academic medical centers and clinical practices with expertise in evidence-based medicine. All major clinical specialties are represented.
If you have questions or feedback, please contact druglist@ingenio-rx.com.
| Clinical Criteria | Associated Medications (as applicable) | Document Number | Coding |
|---|---|---|---|
| Abraxane (paclitaxel, protein bound) | ING-CC-0099 | J9264 | |
| Actimmune (interferon gamma-1b) | ING-CC-0085 | J9216 | |
| Adakveo (crizanlizumab) | ING-CC-0153 | J3490, J3590, J0791, C9053 | |
| Givlaari (givosiran) | ING-CC-0154 | J0223, J3490, J3590, C9056 | |
| Adcetris (brentuximab vedotin) | ING-CC-0092 | J9042 | |
| Agents for Hemophilia A and von Willebrand Disease | Antihemophilic Factor (Human) [Hemofil-M, Koate-DVI, Monoclate-P]. Antihemophilic Factor (Recombinant) [Advate, Afstyla, Helixate FS, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse]. Antihemophilic Factor (Recombinat [Pegylated]) [Adynovate, Jivi, Eloctate, Esperoct]. Antihemophilic Factor (bispecific) [Hemlibra (emicizumab)]. Antihemophilic Factor (Recombinant [Porcine Sequence]) [Obizur]. Antihemophilic Factor/von Willebrand Factor Complex (Human) [Alphanate, Humate-P, Wilate]. von Willebrand factor (Recombinant) [Vonvendi]. | ING-CC-0065 | J7190, J7182, J7185, J7192, J7204, J7209, J7210, J7211, J7205, J7207, J7188, J7191, J7183, J7186, J7187, J7179, J7208, J7170 |
| Agents for Hemophilia B | Factor IX (Human) [Alphanine SD, Mononine. Factor IX Complex (Human) [(Factors II, IX, X)] [Bebulin, Profilnine SD]. Factor IX (Recombinant) [Benefix, Ixinity, Rixubis]. Factor IX (Recombinant [Albumin Fusion Protein]) [Idelvion]. Factor IX (Recombinant [Fc Fusion Protein]) [Alprolix]. Factor IX (Recombinant [Glycopegylated]) [Rebinyn]. | ING-CC-0148 | J7193, J7194, J7195, J7200 J7201, J7202, J7203 |
| Akynzeo (fosnetupitant and palonosetron) for injection | ING-CC-0074 | J1454 | |
| Aldurazyme (laronidase) | ING-CC-0025 | J1931, S9357 | |
| Alimta (pemetrexed disodium) | ING-CC-0094 | J9305 | |
| Aliqopa (copanlisib) | ING-CC-0133 | J9057 | |
| Alpha-1 Proteinase Inhibitor Therapy | Aralast, Glassia, Prolastin-C, Zemaira | ING-CC-0073 | J0256, J0257, S9346 |
| Aristada Initio (aripiprazole lauroxil) | ING-CC-0083 | J1943 | |
| Arzerra (ofatumumab) | ING-CC-0122 | J9302 | |
| Asparagine Specific Enzymes | Asparlas (calaspargase pegol-mknl), Oncaspar (pegaspargase), Erwinaze (asparaginase [erwinia chrysanthemi]) | ING-CC-0096 | J9019, J9020, J9266, J9118 |
| Bavencio (avelumab) | ING-CC-0129 | J9023 | |
| Bendamustine Agents | Bendeka, Treanda, Belrapzo | ING-CC-0116 | J9036, J9033, J9034 |
| Benlysta (belimumab) | ING-CC-0028 | J0490 | |
| Besponsa (inotuzumab ozogamicin) | ING-CC-0131 | J9229 | |
| Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis | Avonex (interferon beta-1a), Plegridy (peginterferon beta-1a), Rebif (interferon beta-1a), Betaseron (interferon beta-1b), Extavia (interferon beta-1b), Copaxone (glatiramer acetate), Glatopa (glatiramer acetate) | ING-CC-0014 | C9399, J1595, J1826, J1830, J3490, Q3027, Q3028, S9559 |
| Bevacizumab for Non-ophthalmologic Indications | Avastin, Mvasi, Zirabev | ING-CC-0107 | J9035, Q5107, Q5118 |
| Blincyto (blinatumomab) | ING-CC-0126 | J9039 | |
| Botulinum Toxin | Botox (OnabotulinumtoxinA), Xeomin (IncobotulinumtoxinA), Dysport (AbobotulinumtoxinA), Myobloc (RimabotulinumtoxinB) | ING-CC-0032 | 31573, 46505, 52287, 64647, 67345, 46505, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, J0585, J0586, J0587, J0588, S2340, S2341 |
| Brineura (cerliponase alfa) | ING-CC-0012 | J0567 | |
| Cablivi (caplacizumab-ydhp) | ING-CC-0137 | J3590, C9047 | |
| Colony Stimulating Factor Agents | Filgrastim agents (Neupogen, Nivestym, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine) | ING-CC-0002 | 96377, J1442, J1447, J2505, J2820, Q5101, Q5108, Q5110, S9537, Q5111, J3590, C9058, Q5120 |
| Complement Inhibitors | Soliris (eculizumab), Ultomiris (ravulizumab-cwvz) | ING-CC-0041 | J1300, J1303 |
| Crysvita (burosumab-twza) | ING-CC-0081 | J0584 | |
| Cyramza (ramucirumab) | ING-CC-0123 | J9308 | |
| Darzalex (daratumumab) | ING-CC-0127 | J9145 | |
| Denosumab agents | Prolia, Xgeva | ING-CC-0027 | J0897 |
| Dihydroergotamine (DHE) injection | ING-CC-0052 | J1110 | |
| Docetaxel | Docefrez | ING-CC-0093 | J9171 |
| Doxorubicin liposome | Doxil, Lipodox | ING-CC-0098 | Q2049, Q2050 |
| Drug dosage, frequency, and route of administration | ING-CC-0136 | ||
| Duopa (carbidopa and levodopa enteral suspension) | ING-CC-0035 | J7340 | |
| Dupixent (dupilumab) | ING-CC-0029 | J3490, J3590 | |
| Durysta (bimatoprost implant) | ING-CC-0163 | J3490, C9399 | |
| Egrifta (tesamorelin) | ING-CC-0069 | J3490, J3590 | |
| Elaprase (idursulfase) | ING-CC-0024 | J1743, S9357 | |
| Elzonris (tagraxofusp-erzs) | ING-CC-0088 | J9269 | |
| Empliciti (elotuzumab) | ING-CC-0117 | J9176 | |
| Enhertu (fam-trastuzumab deruxtecan-nxki) | ING-CC-0158 | J3490, J3590, J9999, J9858, C9399 | |
| Entyvio (vedolizumab) | ING-CC-0071 | J3380 | |
| Enzyme Replacement Therapy for Gaucher Disease | Cerezyme (imiglucerase), Elelyso (taliglucerase), Vpriv (velaglucerase) | ING-CC-0051 | J1786, J3060, J3385, S9357 |
| Erbitux (cetuximab) | ING-CC-0106 | J9055 | |
| Erythropoiesis Stimulating Agents | Aranesp (darbepoetin alfa), Epogen (epoetin alfa), Mircera (methoxy polyethylene glycol-epoetin beta), Procrit (epoetin alfa), Retacrit (epoetin alfa-epbx) | ING-CC-0001 | J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106, S9537, EA, EB EC |
| Evenity (romosozumab-aqqg) | ING-CC-0139 | J3111 | |
| Exondys 51 (eteplirsen) | ING-CC-0044 | J1428 | |
| Ethyol (amifostine) | ING-CC-0155 | J0207 | |
| Fabrazyme (agalsidase beta) | ING-CC-0021 | J0180, S9357 | |
| Faslodex (fulvestrant) | ING-CC-0103 | J9395 | |
| Fuzeon (enfuvirtide) | ING-CC-0055 | J1324 | |
| GamaSTAN [(immune globulin (human)] | GamaSTAN, GamaSTAN S/D | ING-CC-0039 | 90281, J1460, J1560, |
| Gamifant | ING-CC-0087 | J9210 | |
| Gazyva (obinutuzumab) | ING-CC-0121 | J9301 | |
| GnRH Analogs for oncologic indications | Firmagon (degarelix), Zoladex (goserelin acetate), Vantas (histrelin acetate), Eligard (leuprolide acetate), Lupron Depot (leuprolide acetate), and Trelstar, Trelstar LA (triptorelin pamoate) | ING-CC-0102 | J1950, J9202, J9218, S9560, J3315, J9155, J9217, J9225, J1675, J1950, J3315, J9155, J9202 |
| GnRH Analogs for the treatment of non-oncologic indications | Zoladex (goserelin acetate), Supprelin LA (histrelin acetate), Lupron Depot/Depot-Ped (leuprolide acetate), Lupaneta Pack (leuprolide acetate for depot suspension and norethindrone acetate tablets), Synarel Nasal Spray (nafarelin acetate), Triptodur (triptorelin pamoate extended-release), Vantas (histrelin acetate) | ING-CC-0061 | C9399, J3490, J1675, J3315, J3316, J9202, J9218, J9225, J9226, S9560, J1950, J9217 |
| Growth hormone | Somatropin: Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive | ING-CC-0068 | J2940, J2941, Q0515, S9558 |
| H.P. Acthar Gel (repository corticotropin injection) | ING-CC-0004 | J0800 | |
| Halaven (eribulin) | ING-CC-0108 | J9179 | |
| Hereditary Angioedema Agents | Cinryze, Haegarda, Berinert: [C1 Inhibitor (Human)], Ruconest [C1 Inhibitor (Recombinant)], Takhzyro (lanadelumab-flyo), Firazyr (icatibant), Kalbitor (ecallantide) | ING-CC-0034 | J0593, J0596, J0597, J0598, J1290, J1744, J0599 |
| Human Parathyroid Hormone Agents | Bonsity, (teriparatide), Forteo (teriparatide),Tymlos (abaloparatide) | ING-CC-0038 | J3490, C9399, J3110 |
| Hyaluronan Injections | Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synojoynt, Synvisc/-One, Triluron, TriVisc, Visco-3 | ING-CC-0006 | J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, J7333 |
| Hyaluronan Injections - Step Therapy and Quantity Limit - MEDICARE ONLY | Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synojoynt, Synvisc/-One, Triluron, TriVisc, Visco-3 | ING-CC-0005 | J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, J7333 |
| Imfinzi (durvalumab) | ING-CC-0130 | J9173 | |
| Immunoglobulins | Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify | ING-CC-0003 | 90281, 90283, 90284, J1459, J1460, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1566, J1568, J1569, J1572, J1575, J1599, S9338, J3490, J3590, C9399 |
| Implantable and ER Buprenorphine Containing Agents | Probuphine | ING-CC-0030 | 11981, 11983, G0516, G0517, G0518, J0570 |
| Increlex (mecasermin) | ING-CC-0045 | J2170 | |
| Infertility Agents | Menopur (menotropins), Follistim AQ (follitropin beta), Gonal-f/RFF (follitropin beta), Bravelle (urofollitropin), Pregnyl, Novarel: Chorionic Gonadotropin (Human), Ovidrel (Chorionic Gonadotropin (Recombinant), Cetrotide (cetrorelix), Ganirelix, Lupron Depot (leuprolide acetate), Crinone 8% gel, Endometrin, Prochieve 8% gel: progesterone | ING-CC-0015 | J0725, J1950, J3355, J3490, J8499, S0122, S0126, S0128, S0132 |
| Injectable Hydroxyprogesterone for prevention of preterm birth | Makena | ING-CC-0053 | 99506, J1726, J1729, J7999, S9560 |
| Interleukin-1 Inhibitors | Arcalyst (rilonacept), Ilaris (canakinumab,; Kineret (anakinra) | ING-CC-0064 | J2793, J0638, J3490, J3590 |
| Intravitreal Corticosteroid Implants | Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant) | ING-CC-0031 | J7314, 67027, J7311, 08H033Z, 08H133Z, 67028, J7313, 67028, J7312 |
| Istodax (romidepsin) | ING-CC-0100 | J9315 | |
| Ixempra (ixabepilone) | ING-CC-0090 | J9207 | |
| Jelmyto (mitomycin) | ING-CC-0165 | J9999, J3490, C9399 | |
| Jetrea (ocriplasmin) | ING-CC-0070 | 67028 J7316 |
|
| Jevtana (cabazitaxel) | ING-CC-0114 | J9043 | |
| Kadcyla (ado-trastuzumab) | ING-CC-0115 | J9354 | |
| Kanuma (sebelipase alfa) | ING-CC-0037 | J2840 |
|
| Keytruda (pembrolizumab) | ING-CC-0124 | J9271 | |
| Krystexxa (pegloticase) | ING-CC-0057 | J2507 |
|
| Kymriah (tisagenlecleucel) | ING-CC-0150 | 0537T, 0538T, 0539T, 0540T, Q2042
|
|
| Kyprolis (carfilzomib) | ING-CC-0120 | J9047 | |
| Lartruvo (olaratumab) | ING-CC-0091 | J9285 | |
| Lemtrada (alemtuzumab) | ING-CC-0009 | J0202 |
|
| Levoleucovorin Agents | Fusilev, Khapzory | ING-CC-0104 | J0641, J0642 |
| Libtayo (cemiplimab-rwlc) | ING-CC-0145 | J9119 | |
| Lumizyme (alglucosidase alfa) | ING-CC-0018 | J0221, S9357 | |
| Lumoxiti (moxetumomab pasudotox-tdfk) | ING-CC-0144 | J9313 | |
| Melanoma Vaccines | Imlygic (talimogene laherparepvec), other melanoma vaccines | ING-CC-0135 | J9325, J3590 |
| Mepsevii (vestronidase alfa) | ING-CC-0013 | J3397 | |
| Monoclonal Antibodies to Interleukin-17 | Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab) | ING-CC-0042 | C9399, J3490, J3590 |
| Monoclonal Antibodies to Interleukin-23 | Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab) | ING-CC-0050 | J1628, J3245, J3490, J3590 |
| Monoclonal Antibodies to Interleukin-5 | Cinqair (reslizumba), Fasenra (benralizumab), Nucala (mepolizumab) | ING-CC-0043 | J0517, J2182, J2786 |
| Monoclonal Antibodies to Interleukin-6 | Actemra (tocilizumab), Kevzara (sarilumab) | ING-CC-0066 | J3262, C9399, J3490, J3590 |
| Mozobil (plerixafor) | ING-CC-0089 | J2562 | |
| Mylotarg (gemtuzumab ozogamicin) | ING-CC-0132 | J9203 | |
| Naglazyme (galsulfase) | ING-CC-0023 | J1458, S9357 | |
| Naltrexone Implantable Pellets | ING-CC-0036 | 11981, 11983, 17999, 22999, 49999, J3490, J7999 | |
| Nplate (romiplostim) | ING-CC-0111 | J2796 | |
| Nulojix (belatacept) | ING-CC-0076 | J0485 | |
| Ocrevus (ocrelizumab) | ING-CC-0011 | J2350 | |
| Octreotide Agents | Bynfezia, Sandostatin, Sandostatin LAR Depot | ING-CC-0058 | J2353, J2354 |
| Off Label Drug and Approved Orphan Drug Use | ING-CC-0141 | ||
| Onpattro (patisiran) | ING-CC-0082 | J0222 | |
| Opdivo (nivolumab) | ING-CC-0125 | J9299 | |
| Orencia (abatacept) | ING-CC-0078 | J0129 | |
| Padcev (enfortumab vedotin-ejfv) | ING-CC-0157 | J9177, J9999, C9399, J3490 | |
| Palynziq (pegvaliase-pqpz) | ING-CC-0077 | C9399, J3590 | |
| Perjeta (pertuzumab) | ING-CC-0110 | J9306 | |
| Polivy (polatuzumab vedotin-piiq) | ING-CC-0143 | J9309 | |
| Prialt (ziconotide) | ING-CC-0040 | J2278 | |
| Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors | Praluent (alirocumab), Repatha (evolocumab) | ING-CC-0010 | J3490, J3590 |
| Prostacyclin Infusion and Inhalation Therapy | Flolan (epoprostenol), Remodulin (treprostinil), Tyvaso (treprostinil), Veletri (epoprostenol), Ventavis (iloprost) | ING-CC-0067 | J1325, J3285, J7686, K0455, Q4074, S0155, S9347 |
| Provenge (sipuleucel-T) | ING-CC-0134 | Q2043 | |
| Radicava (edaravone) | ING-CC-0049 | J1301 | |
| Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy | Azedra (iobenguane I 131), Lutathera (lutetium Lu 177 dotatate), Zevalin (ibritumomab tiuxetan) | ING-CC-0118 | A9543, 79403, A9699, 79101, A9513, A9590 |
| Reblozyl (luspatercept) | ING-CC-0156 | J0896, C9399, J3490, J3590 | |
| Rituximab agents for Non-Oncologic Indications | Rituxan, Ruxience, Truxima | ING-CC-0075 | Q5115, Q5119, J3490, J9312, J3590 |
| Sarclisa (isatuximab-irfc) | ING-CC-0161 | C9399, J3490, J3590, J9999 | |
| Selected Injectable 5HT3 Antiemetic Agents | Aloxi injection (palonosetron) | ING-CC-0056 | J2469 |
| Selected Injectable NK-1 Antiemetic Agents | Cinvanti injection (aprepitant), Emend injection (aprepitant), Varubi injection (rolapitant) | ING-CC-0059 | J1453, J0185, J2797 |
| Selected Progestins | Crinone, Progesterone suppositories | ING-CC-0054 | |
| Selective Vascular Endothelial Growth Factor (VEGF) Antagonists | Avastin, Mvasi, Zirabev (bevacizumab, bevacizumab-awwb, bevacizumab-bvzr), Lucentis (ranibizumab), Eylea (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll) | ING-CC-0072 | Q5118, 67028, J2503, 67028, C9257, J9035, Q5107, 67028, J2778, 67028, J0178, J0179, J3490, J3590 |
| Scenesse (afamelanotide) | ING-CC-0159 | J3490, J3590 | |
| Spinraza (nusinersen) | ING-CC-0048 | 96450, J2326 | |
| Spravato (esketamine) | ING-CC-0086 | J3490 | |
| Stelara (ustekinumab) | ING-CC-0063 | J3357, J3358 | |
| Strensiq (asfotase alfa) | ING-CC-0079 | J3490 | |
| Sylvant (siltuximab) | ING-CC-0113 | J2860 | |
| Synagis (palivizumab) | ING-CC-0007 | 90378, S9562 | |
| Tecentriq (atezolizumab) | ING-CC-0128 | J9022 | |
| Select Clotting Agents for Bleeding Disorders | FEIBA [Anti-inhibitor Coagulant Complex (Human)], Coagadex [Factor X (Human)], Novoseven RT [Factor VIIa (Recombinant)], Corifact [Factor XIII Concentrate (Human)], Tretten [Factor XIII A-Subunit (Recombinant)], RiaSTAP, Fibryga: [Fibrinogen Concentrate (Human)] | ING-CC-0149 | J7198, J7189, J7175, J7180 , J7181, J7177, J7178 |
| Tegsedi (inotersen) | ING-CC-0084 | J3490, C9399 | |
| Tepezza (teprotumumab-trbw) | ING-CC-0162 | J3490, J3590, C9061 | |
| Somatuline Depot (lanreotide) | ING-CC-0142 | J1930 | |
| Subcutaneous Hormonal Implants | Testopel (testosterone), estrogen containing implants | ING-CC-0008 | 11980, S0189, J3490 |
| Testosterone, Injectable | Depo-Testosterone (testosterone cypionate), Xyosted (testosterone enanthate), Aveed (testosterone undecanoate) | ING-CC-0026 | J1071, J3121, J3145, J3490, C9399 |
| Torisel (temsirolimus) | ING-CC-0101 | J9330 | |
| Trodelvy (sacituzumab govitecan) | ING-CC-0165 | J9999, J3590, J3490, C9399 | |
| Trogarzo (ibalizumab-uiyk | ING-CC-0047 | J1746 | |
| Tumor Necrosis Factor Antagonists | Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hyrimoz, Hadlima), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Avsola, Inflectra, Renflexis) | ING-CC-0062 | J0135, J0717, J1438, J1602, J1745, J3590, Q5103, Q5104, Q5109, Q5121, S9359, C9399 |
| Tysabri (natalizumab) | ING-CC-0020 | J2323 | |
| Vectibix (panitumumab) | ING-CC-0105 | J9303 | |
| Velcade (bortezomib) | ING-CC-0095 | J9041, J9044 | |
| Vidaza (azacitidine) | ING-CC-0097 | J9025 | |
| Vimizim (elosulfase alfa) | ING-CC-0022 | J1322, S9357 | |
| Vyepti (eptinezumab) | ING-CC-0160 | C9063, J3490, J3590 | |
| Vyondys 53 (golodirsen) | ING-CC-0152 | J1429, J3490, J3590, C9399, C9063 | |
| Xiaflex (clostridial collagenase histolyticum) injection | ING-CC-0017 | 20527, 26341, J0775 | |
| Xofigo (Radium Ra 223 Dichloride) | ING-CC-0112 | A9606, 79101 | |
| Xolair (omalizumab) | ING-CC-0033 | J2357 | |
| Yervoy (ipilimumab) | ING-CC-0119 | J9228 | |
| Yescarta (axicabtagene ciloleucel) | ING-CC-0151 | 0537T, 0538T, 0539T, 0540T, Q2041 | |
| Zaltrap (ziv-aflibercept) | ING-CC-0109 | J9400 | |
| Zinplava (bezlotoxumab) | ING-CC-0046 | J0565 | |
| Zoledronic Acid Agents | Reclast, Zometa | ING-CC-0019 | J3489 |
| Zulresso (brexanolone) | ING-CC-0140 | J3490, C9055, J3590 |