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
Adcetris (brentuximab vedotin) ING-CC-0092 J9042
Agents for Hemophilia and von Willebrand Disease FEIBA, Novoseven RT, Hemofil-M, Koate-DVI, Monoclate-P, Advate, Afstyla, Helixate FS, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse, Adynovate, Jivi, Eloctate, Hemlibra, Obizur, Alphanate, Humate-P, Wilate, Vonvendi, Alphanine SD, Mononine, Bebulin, Profilnine SD, Benefix, Ixinity, Rixubis, Idelvion, Alprolix, Rebinyn, Coagadex, Corifact, Tretten, RiaSTAP, Fibryna/Fibryga ING-CC-0065 J7198, J7189, J7190, J7182, J7185, J7192, J7209, J7210, J7211, J7205, J7207, J7192, J7170, J7188, J7191, J7183, J7186, J7187, J7179, J7193, J7194, J7195, J7200, J7201, J7202, J7203, J7175, J7180, J7181, J7177, J7178, J7208
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 Oncaspar (pegaspargase), Erwinaze (asparaginase [erwinia chrysanthemi]) ING-CC-0096 J9019, J9020, J9266
Asparlas (calaspargase pegol-mknl) ING-CC-0138 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, Xeomin, Dysport, Myobloc 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 Neupogen, Nivestym, Zarxio, Neulasta, Fulphila, Udenyca, Leukine, Prokine, Granix  ING-CC-0002 96377, J1442, J1447, J2505, J2820, Q5101, Q5108, Q5110, S9537, Q5111
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 Taxotere, 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
Egrifta (tesamorelin) ING-CC-0069 J3490
Elaprase (idursulfase) ING-CC-0024 J1743, S9357
Elzonris (tagraxofusp-erzs) ING-CC-0088 J9269
Empliciti (elotuzumab) ING-CC-0117 J9176
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
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, Supprelin LA, Lupron Depot/Depot-Ped, Lupaneta Pack, Synarel Nasal Spray, Triptodur, Vantas 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, Takhzyro, Firazyr, Ruconest, Kalbitor ING-CC-0034 J0593, J0596, J0597, J0598, J1290, J1744, J0599
Human Parathyroid Hormone Agents Tymlos (abaloparatide), Forteo (teriparatide)   ING-CC-0038 J3490
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
Imfinzi (durvalumab) ING-CC-0130 J9173
Immunoglobulins Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen ING-CC-0003
90281, 90283, 90284, J1459, J1460, J1555, J1556, J1557, 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, Follistim AQ, Gonal-f/RFF, Bravelle, Pregnyl, Novarel, Ovidrel, Cetrotide, Ganirelix, Lupron Depot, Crinone 8% gel, Endometrin, Prochieve 8% gel 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
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
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, C9043
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 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
Palynziq (pegvaliase-pqpz) ING-CC-0077 C9399, J3590
Perjeta (pertuzumab) ING-CC-0110 J9306
Polivy (polatuzumab vedotin-piiq) ING-CC-0143 J9999, C9399
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, Lutathera, Zevalin ING-CC-0118 A9543, 79403, A9699, C9408, 79101, A9513
Rituximab agents for Non-Oncologic Indications Rituxan, Ruxience, Truxima ING-CC-0075 Q5115, J3490, J9312
Selected Injectable 5HT3 Antiemetic Agents Aloxi injection ING-CC-0056 J2469
Selected Injectable NK-1 Antiemetic Agents Emend injection, Varubi injection, Cinvanti injection 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) ING-CC-0072 Q5118, 67028, J2503, 67028, C9257, J9035, Q5107, 67028, J2778, 67028, J0178, 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
Tegsedi (inotersen) ING-CC-0084 J0222, C9399
Somatuline Depot (lanreotide) ING-CC-0142 J1930
Subcutaneous Hormonal Implants Testopel, 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
Trogarzo (ibalizumab-uiyk ING-CC-0047 J1746
Tumor Necrosis Factor Antagonists Adalimumab agents (Humira, Amjevita, Cyltezo, Hyrimoz), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Inflectra, Renflexis) ING-CC-0062 J0135, J0717, J1438, J1602, J1745, J3590, Q5103, Q5104, Q5109, S9359
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
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
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, C9399