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 |
| 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 | |
| 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 |