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 clinical criteria documents for all injectable oncology drugs will be posted on this page mid-2019. 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. You can also perform a search by entering any of the information from the table into the Search box.

Please note: Clinical criteria for orals or self-injectables can be found in our Searchable drug lists within the Drug List Search tab. Enter the name of the drug you’re looking for, select the drug and dose you want and click on Clinical Criteria under the Notes & Restrictions section.

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 IngenioRx* 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@anthem.com.

Clinical Criteria
Associated Medications (as applicable) Document Number Coding
Agents for Hereditary Angioedema Cinryze, Haegarda, Berinert, Takhzyro, Berinert, Firazyr, Ruconest, Kalbitor ING-CC-0034 J0596, J0597, J0598, J1290, J1744, J0599, J3490, J3590, C9399
Zoledronic Acid Agents ING-CC-0019 J3489
Akynzeo (fosnetupitant and palonosetron) for Injection Akynzeo ING-CC-0074 J8655
Aldurazyme (laronidase) ING-CC-0025 J1931, S9357
Alpha-1 Proteinase Inhibitor Therapy Aralast, Glassia, Prolastin-C, Zemaira ING-CC-0073 J0256, J025, 7S9346
Antihemophilic Factors and Clotting Factors 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
Aristada Initio (aripiprazole lauroxil) Aristada ING-CC-0083 C9035, J3490
Benlysta (belimumab) Benlysta ING-CC-0028 J0490
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 J1595, J1826, J1830, J3490, Q3027, Q3028, S9559
Botulinum Toxin Botox, Xeomin, Dysport, Myobloc ING-CC-0032 31573, 46505, 52287, 64612, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 67345, 46505, 52287, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, J0585, J0586, J0587, J0588, S2340, S2341, J0585, J0586, J0587, J0588, S2340, S2341
Brineura (cerliponase alfa) ING-CC-0012 J0567
Colony Stimulating Factor Agents Neupogen, Nivestym, Zarxio, Neulasta, Fulphila, Leukine, Granix ING-CC-0002 96377, J1442, J1447, J2505, J2820, Q5101, Q5108, Q5110, S9537
Crysvita (burosumab-twza) ING-CC-0081 J0584
Denosumab agents Prolia, Xgeva ING-CC-0027 J0897
Dihydroergotamine (DHE) Injection ING-CC-0052 J1110
Dupixent (dupilumab) Dupixent (dupilumab) ING-CC-0029 J3490, J3590
Egrifta (tesamorelin) Egrifta (tesamorelin) ING-CC-0069 J3490
Elaprase (idursufase) ING-CC-0024 J1743, S9357
Entyvio (vedolizumab) ING-CC-0071 J1743, S9357
Enzyme Replacement Therapy for Gaucher Disease Cerezyme (imiglucerase), Elelyso (taliglucerase), Vpriv (velaglucerase) ING-CC-0051 J1786, J3060, J3385, S9357
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
Exondys 51 (eteplirsen) ING-CC-0044 J1428
Fabrazyme (agalsidase beta) ING-CC-0021 J0180, S9357
Fuzeon (enfuvirtide) ING-CC-0055 J1324
GamaSTAN [(immune globulin (human)] GamaSTAN. GamaSTAN S/D ING-CC-0039 90281, J1460, J1560
GnRH Analogs for the treatment of non-oncologic indications Zoladex, Supprelin LA, Lupron Depot/Depot-Ped, Lupaneta Pack, Synarel Nasal Spray, Triptodur ING-CC-0061 C9399, J3490, J1675, J1950, J3315, J3316, J9202, J9217, J9218, J9225, J9226, J3490, S9560
Growth hormone Somatostatin: 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
Human Parathyroid Hormone Agents Tymlos (abaloparatide), Forteo (teriparatide) ING-CC-0038 J3490, J3110
Hyaluronan Injections Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synvisc/-One, TriVisc, Visco-3 ING-CC-0006 J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329
Immunoglobulins Bivigam, Carimune NF, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen ING-CC-0003 90281, 90284, J1459, J1460, J1555, J1556, J1557, J1559, J1560, J1561, J1566, J1568, J1569, J1572, J1575, J1599, S9338
Implantable and ER Buprenorphine Containing Agents Probuphine, Sublocade ING-CC-0030 11981, 11983, G0516, G0517, G0518, J0570, J3490, Q9991, Q9992
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
Jetrea (ocriplasmin) Jetrea (ocriplasmin) ING-CC-0070 67028, J7316
Kanuma (sebelipase alfa) ING-CC-0037 J2840
Krystexxa (pegloticase) Krystexxa ING-CC-0057 J2507
Lemtrada (alemtuzumab) ING-CC-0009 J0202
Lumizyme (alglucosidase alfa) Lumizyme ING-CC-0018 J0221, S9357
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), Tremfya (guselkumab) ING-CC-0050 J1628, J3245
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
Naglazyme (galsulfase) ING-CC-0023 J1458, S9357
Nulojix (belatacept) Nulojix (belatacept) ING-CC-0076 J0485
Ocrevus (ocrelizumab) ING-CC-0011 J2350
Octreotide Agents Sandostatin, Sandostatin LAR Depot ING-CC-0058 J2353, J2354
Onpattro (patisiran) ING-CC-0082 C9399, J3490
Orencia (abatacept) ING-CC-0078 J0129
Palynziq (pegvaliase-pqpz) ING-CC-0077 C9399, J3590
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
Radicava (edaravone) Radicava (edaravone) ING-CC-0049 J1301
Rituxan (rituximab) for Non-Oncologic Indications ING-CC-0075 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 N/A
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists Avastin, Mvasi (bevacizumab), Lucentis (ranibizumab), Eylea (aflibercept) ING-CC-0072 67028, J2503, 67028, C9257, J9035, Q5107, 67028, J2778, 67028, J0178
Soliris (eculizumab) ING-CC-0041 J1300
Spinraza (nusinersen) Spinraza (nusinersen) ING-CC-0048 96450, J2326
Stelara (ustekinumab) ING-CC-0063 J3357, J3358
Strensiq (asfotase alfa) Strensiq (asfotase alfa) ING-CC-0079 J3490
Synagis (palivizumab) ING-CC-0007 90378, S9562
Tegsedi (inotersen) ING-CC-0084 C9399, J3490
Testopel (testosterone subcutaneous implant) ING-CC-0008 11980, S0189
Testosterone, Injectable ING-CC-0026 J1071, J3121, J3145
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
Vimizim (elosulfase alfa) ING-CC-0022 J1322, S9357
Vivitrol (extended-release, injectable naltrexone) Injection Vivitrol ING-CC-0016 J2315
Xiaflex (clostridial collagenase histolyticum) injection ING-CC-0017 20527, 26341, J0775
Xolair (omalizumab) ING-CC-0033 J2357
Zinplava (bezlotoxumab) ING-CC-0046 J0565
Intravitreal Corticosteroid Implants Ozurdex (dexamethasone intravitreal implant), Retisert (Fluocinolone acetonide intravitreal implant), Iluvien (fluocinolone acetonide intravitreal implant ING-CC-0031 J7311
Naltrexone implantable pellets ING-CC-0036 J3490, J7999
Duopa (carbidopa and levodopa enteral suspension) ING-CC-0035 J7340

*IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem.