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.
To determine if a code requires authorization, use the
Prior authorization look up tool.
Please refer to the
Louisiana Medicaid Single PDL (Fee for Service and Managed Care Organizations) for criteria that is not found in the searchable tool below.
The clinical criteria information is alphabetized in the table below.
If you have questions or feedback, please contact druglist@carelon.com.
| Clinical Criteria | Associated Medications (as applicable) | Document Number | Coding |
|---|---|---|---|
| Abecma (idecabtagene vicleucel) | CC-0195 | C9081, J3490, J3590, J9999, Q2055 | |
| Abraxane (paclitaxel, protein bound) | CC-0099 | J9264 | |
| Adcetris (brentuximab vedotin) | CC-0092 | J9042 | |
| Iron Agents | Feraheme (ferumoxytol), Ferrlecit (sodium ferric gluconate/sucrose complex), Infed (iron dextran), Injectafer (ferric carboxymaltose), Monoferric (ferric derisomaltose), Triferic/Triferic AVNU (ferric pyrophosphate citrate), Venofer (iron sucrose) | CC-0182 | J1443, J1445, J1437, Q0138, J2916, J1750, J1756, J1439 |
| Aliqopa (copanlisib) | CC-0133 | J9057 | |
| Alpha-1 Proteinase Inhibitor Therapy | Aralast, Glassia, Prolastin-C, Zemaira | CC-0073 | J0256, J0257 |
| Arzerra (ofatumumab) | CC-0122 | J9302 | |
| Asparagine Specific Enzymes | Asparlas (calaspargase pegol-mknl), Oncaspar (pegaspargase), Erwinaze (asparaginase [erwinia chrysanthemi]) , Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) | CC-0096 | J9019, J9020, J9021, J9266, J9118 |
| Bavencio (avelumab) | CC-0129 | J9023 | |
| Beleodaq (belinostat) | CC-0176 | J9032 | |
| Bendamustine Agents | Bendeka, Treanda, Belrapzo, Vivimusta | CC-0116 | J9036, J9033, J9034, J9056, J9058, J9059 |
| Besponsa (inotuzumab ozogamicin) | CC-0131 | J9229 | |
| BESREMi (ropeginterferon alfa-2b-njft) | CC-0206 | J3490, J3590, J9999, C9399 | |
| Briumvi | CC-0227 | J3490, J3590 | |
| Bevacizumab for Non-ophthalmologic Indications | Avastin, Alymsys, Avzivi, Mvasi, Vegzelma, Zirabev | CC-0107 | J3490, J3590, J9035, Q5107, Q5118, Q5126, Q5129 |
| Blincyto (blinatumomab) | CC-0126 | J9039 | |
| Elahere (mirvetuximab) | CC-0226 | J3590, J9999, C9146 | |
| Breyanzi (lisocabtagene maraleucel) | CC-0187 | Q2054 | |
| Brineura (cerliponase alfa) | CC-0012 | J0567 | |
| Cosela (trilaciclib) | CC-0192 | J1448 | |
| Crysvita (burosumab-twza) | CC-0081 | J0584 | |
| Cyramza (ramucirumab) | CC-0123 | J9308 | |
| Danyelza (naxitamab-gqgk) | CC-0184 | J9348 | |
| Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj) | CC-0127 | J9145, J9144 |
| Docetaxel | Docefrez | CC-0093 | J9171 |
| Doxorubicin liposome | Doxil | CC-0098 | Q2049, Q2050 |
| Drug dosage, frequency, and route of administration | CC-0136 | ||
| Durysta (bimatoprost implant) | CC-0163 | J7351 | |
| Elzonris (tagraxofusp-erzs) | CC-0088 | J9269 | |
| Empliciti (elotuzumab) | CC-0117 | J9176 | |
| Enhertu (fam-trastuzumab deruxtecan-nxki) | CC-0158 | J9358 | |
| Erbitux (cetuximab) | CC-0106 | J9055 | |
| Ethyol (amifostine) | CC-0155 | J0207 | |
| Fyarro (sirolimus albumin bound) | CC-0205 | J9331 | |
| Gamifant | CC-0087 | J9210 | |
| Gazyva (obinutuzumab) | CC-0121 | J9301 | |
| Halaven (eribulin) | CC-0108 | J9179 | |
| Hyaluronan Injections | Durolane, Euflexxa, Gel-One, Gel-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synojoynt, Synvisc/-One, Triluron, TriVisc, Visco-3 | CC-0006 | J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332 |
| Imcivree (setmelanotide) | CC-0188 | J3590, C9399 | |
| Imfinzi (durvalumab) | CC-0130 | J9173 | |
| Imjudo (tremelimumab-actl) | CC-0223 | J9999, J3590, J3490, C9147 | |
| Implantable and ER Buprenorphine Containing Agents | Probuphine | CC-0030 | 11981, 11983, G0516, G0517, G0518, J0570 |
| Infertility Agents and HCG Agents | Menopur (menotropins), Follistim AQ (follitropin beta), Gonal-f/RFF (follitropin beta), Pregnyl, Novarel: Chorionic Gonadotropin (Human), Ovidrel (Chorionic Gonadotropin (Recombinant), Cetrotide (cetrorelix), Ganirelix, Lupron Depot (leuprolide acetate), Crinone 8% gel, Endometrin vaginal insert: progesterone | CC-0015 | J0725, J1950, J3490, J8499, S0122, S0126, S0128, S0132 |
| Istodax (romidepsin) | CC-0100 | J9318, J9319 | |
| Ixempra (ixabepilone) | CC-0090 | J9207 | |
| Jelmyto (mitomycin) | CC-0164 | J9281 | |
| Jemperli (dostarlimab-gxly) | CC-0197 | J9272 | |
| Jevtana (cabazitaxel) | CC-0114 | J9043 | |
| Kadcyla (ado-trastuzumab) | CC-0115 | J9354 | |
| Kanuma (sebelipase alfa) | CC-0037 | J2840 |
|
| Keytruda (pembrolizumab) | CC-0124 | J9271 | |
| Kymriah (tisagenlecleucel) | CC-0150 | 0537T, 0538T, 0539T, 0540T, Q2042
|
|
| Kyprolis (carfilzomib) | CC-0120 | J9047 | |
| Levoleucovorin Agents | Fusilev, Khapzory | CC-0104 | J0641, J0642 |
| Libtayo (cemiplimab-rwlc) | CC-0145 | J9119 | Lumoxiti (moxetumomab pasudotox-tdfk) | CC-0144 | J9313 |
| Margenza (margetuximab-cmkb) | CC-0186 | J9353 | |
| Melanoma Vaccines | Imlygic (talimogene laherparepvec), other melanoma vaccines | CC-0135 | J9325, J3590 |
| Monjuvi (tafasitamab-cxix) | CC-0180 | J9349 | |
| Mylotarg (gemtuzumab ozogamicin) | CC-0132 | J9203 | |
| Naltrexone Implantable Pellets | CC-0036 | 11981, 11983, 17999, 22999, 49999, J3490, J7999 | |
| Nulojix (belatacept) | CC-0076 | J0485 | |
| Vyjuvek (beremagene geperpavec) | CC-0243 | J3490, J3590 | |
| Epkinly (epcoritamab-bysp) | CC-0242 | J3490, J3590, J9999, C9399 | |
| Elfabrio (pegunigalsidase alfa-iwxj) | CC-0241 | J3490, J3590 | |
| Octreotide Agents | Bynfezia, Sandostatin, Sandostatin LAR Depot | CC-0058 | J2353, J2354 |
| Off Label Drug and Approved Orphan Drug Use | CC-0141 | ||
| Opdivo (nivolumab) | CC-0125 | J9299 | |
| Padcev (enfortumab vedotin-ejfv) | CC-0157 | J9177 | |
| Pedmark (sodium thiosulfate injection) | CC-0224 | J0208 | |
| Pemetrexed Agents | Alimta, Pemfexy | CC-0094 | J9304, J9305, J9314 |
| Pepaxto (melphalan flufenamide; melflufen) | CC-0191 | J9247 | |
| Perjeta (pertuzumab) | CC-0110 | J9306 | |
| Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf) | CC-0169 | J9316 | |
| Polivy (polatuzumab vedotin-piiq) | CC-0143 | J9309 | |
| Prialt (ziconotide) | CC-0040 | J2278 | |
| Provenge (sipuleucel-T) | CC-0134 | Q2043 | |
| Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy | Azedra (iobenguane I 131), Lutathera (lutetium Lu 177 dotatate), Pluvicto (lutetium Lu 177), Zevalin (ibritumomab tiuxetan) | CC-0118 | A9543, 79403, A9699, 79101, A9513, A9590, A9607 |
| Relizorb (immobilized lipase) cartridge | CC-0198 | B4105 | |
| Adstiladrin (nadofaragene firadenovec-vncg) | CC-0230 | J9999 | |
| Lamzede (velmanase alfa-tycv) | CC-0231 | J3490, C9399 | |
| Lunsumio (mosunetuzumab-axgb) | CC-0232 | J3490, J3590, J9999, C9399 | |
| Rebyota (fecal microbiota, live – jslm) | CC-0233 | J1440 | |
| Revcovi (elapegademase-lvlr) | CC-0235 | J3590, C9399 | |
| Syfovre (pegcetacoplan) | CC-0234 | J3490, C9399 | |
| Rituximab agents for Non-Oncologic Indications | Rituxan, Riabni, Ruxience, Truxima | CC-0075 | J9312, Q5115, Q5119, Q5123 |
| Rituximab agents for Oncologic Indications | Rituxan, Riabni, Ruxience, Truxima | CC-0167 | J9312, Q5115, Q5119, Q5123 |
| Sarclisa (isatuximab-irfc) | CC-0161 | J9227 | |
| Scenesse (afamelanotide) | CC-0159 | J7352 | |
| Signifor LAR (pasireotide) | CC-0236 | J2502 | |
| Sylvant (siltuximab) | CC-0113 | J2860 | |
| Synribo (omacetaxine mepesuccinate) | CC-0178 | J9262 | |
| Tecartus (brexucabtagene autoleucel) | CC-0168 | Q2053 | |
| Tecvayli (teclistamab-cqyv) | CC-0222 | J9999, J3490, J3590, C9148 | |
| Tecentriq (atezolizumab) | CC-0128 | J9022 | |
| Tepezza (teprotumumab-trbw) | CC-0162 | J3241 | |
| Somatuline Depot (lanreotide) | CC-0142 | J1930, J1932 | |
| Subcutaneous Hormonal Implants | Testopel (testosterone), estrogen containing implants | CC-0008 | 11980, S0189, J3490 |
| Testosterone, Injectable | Depo-Testosterone (testosterone cypionate), Xyosted (testosterone enanthate), Aveed (testosterone undecanoate) | CC-0026 | J1071, J3121, J3145 |
| Torisel (temsirolimus) | CC-0101 | J9330 | |
| Trastuzumab Agents | Herceptin (trastuzumab), Herzuma (trastuzumab-pkrb), Kanjinti (trastuzumab-anns), Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), Trazimera (trastuzumab-qyyp), Herceptin Hylecta (trastuzumab; hyaluronidase-oysk) | CC-0166 | J9356, J9355, Q5113, Q5117 Q5114, Q5112, Q5116 |
| Trodelvy (sacituzumab govitecan) | CC-0165 | J9317 | |
| Tzield (teplizumab-mzwv) | CC-0225 | J9381 | |
| Uplizna (inebilizumab-cdon) | CC-0170 | J1823 | |
| Vectibix (panitumumab) | CC-0105 | J9303 | |
| Velcade (bortezomib) | CC-0095 | J9041, J9044 | |
| Vidaza (azacitidine) | CC-0097 | J9025 | |
| Xiaflex (clostridial collagenase histolyticum) injection | CC-0017 | 20527, 26341, J0775 | |
| Xofigo (Radium Ra 223 Dichloride) | CC-0112 | A9606, 79101 | |
| Yervoy (ipilimumab) | CC-0119 | J9228 | |
| Yescarta (axicabtagene ciloleucel) | CC-0151 | 0537T, 0538T, 0539T, 0540T, Q2041 | |
| Zaltrap (ziv-aflibercept) | CC-0109 | J9400 | |
| Zepzelca (lurbinectedin) | CC-0171 | J9223 | |
| Zilretta (triamcinolone acetonide extended-release) | CC-0177 | J3304 | |
| Zinplava (bezlotoxumab) | CC-0046 | J0565 | |
| Zynlonta (loncastuximab tesirine-lpyl) | CC-0196 | J9359 | |
| Rybrevant (amivantamab-vmjw) | CC-0201 | J9061 | |
| Ryplazim (plasminogen, human-tvmh) | CC-0203 | J2998 | |
| Tivdak (tisotumab vedotin-tftv) | CC-0204 | J9273 | |
| Vyvgart (efgartigimod alfa-fcab) | CC-0207 | J9332 | |
| Kimmtrak (tebentafusp-tebn) | CC-0211 | J9274 | |
| Vascular Endothelial Growth Factor (VEGF) Inhibitors | Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumab-awwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa) | CC-0072 | Q5118, C9257, J9035, Q5107, J2778, J0178, J0179, Q5124, J2777, Q5126, Q5128, Q5129 |
| Enjaymo (sutimlimab-jome) | CC-0210 | J1302 | |
| Carvykti (ciltacabtagene autoleucel) | CC-0214 | Q2056 | |
| Opdualag (nivolumab and relatlimab-rmbw) | CC-0216 | J9298 | |
| Amvuttra (vutrisiran) | CC-0217 | J0225 | |
| Xipere (triamcinolone acetonide injectable suspension) | CC-0218 | J3490, C9092 | |
| Leqembi (lecanemab) | CC-0228 | J3490, J3590 | |
| Sunlenca (lenacapavir) | CC-0229 | J1961 | |
| Ycanth (cantharidin) | CC-0251 | J3490 | |
| Elrexfio (elranatamab-bcmm) | CC-0248 | J3490, J3590, J9999, C9399 | |
| Talvey (talquetamab-tgvs) | CC-0249 | J3490, J3590, J9999, C9399 | |
| Veopoz (pozelimab-bbfg) | CC-0250 | J3590, C9399 | |
| Beyfortus (nirsevimab) | CC-0247 | 90380, 90381, 96372 | |
| Natalizumab Agents (Tysabri, Tyruko) | Tysabri (natalizumab), Tyruko (natalizumab-sztn) | CC-0020 | J3490, J3590 |
| Aphexda (motixafortide) | CC-0253 | J3490, J3590, J9999 | |
| Adzynma (ADAMTS13, recombinant-krhn) | CC-0252 | J3590, C9399 | |
| Zilbrysq (zilucoplan) | CC-0254 | J3490 | |
| Korsuva (difelikefalin acetate) | CC-0219 | J0879 | |
| Izervay (avacincaptad pegol) | CC-0245 | J3490, J3590, J9999, C9162 | |
| Loqtorzi (toripalimab-tpzi) | CC-0255 | J3490, J3590, C9399 | |
| Rivfloza (nedosiran) | CC-0256 | J3490 | |
| Wainua (eplontersen) | CC-0257 | J3490, C9399 |