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 Precertification lookup tool
The New Jersey Medicaid state-specific clinical criteria information is alphabetized below. Not all drugs requiring authorization have New Jersey Medicaid State specific criteria. If a code requires authorization and the clinical criteria document is not found in the list below, please utilize the following link for additional criteria.Clinical Criteria
NEW JERSEY SPECIFIC POLICIES
| Clinical Criteria | Associated Medications (as applicable) | Document Number | Coding |
|---|---|---|---|
| Cablivi (caplacizumab-yhdp) | Cablivi (caplacizumab-yhdp) | NJ CAID-0137 | J3590, C9047 |
| Complement Inhibitors | Soliris (eculizumab), Ultomiris (ravulizumab-cwvz) | NJ CAID-0041 | J1300, J1303 |
| Dupixent (dupilumab) | Dupixent (dupilumab) | NJ CAID-0029 | C9399, J3590 |
| Elaprase (idursulfase) | Elaprase (idursulfase) | NJ CAID-0024 | J1743, S9357 |
| Empaveli (pegcetacoplan) | Empaveli (pegcetacoplan) | NJ CAID-0199 | J3490, C9399 |
| Enzyme Replacement Therapy for Gaucher Disease | Cerezyme (imiglucerase), Elelyso (taliglucerase), Vpriv (velaglucerase) | NJ CAID-0051 | J1786, J3060, J3385, S9357 |
| Fabrazyme (agalsidase beta) | Fabrazyme (agalsidase beta) | NJ CAID-0021 | J0180, S9357 |
| Gamifant | Gamifant | NJ CAID-0087 | J9210 |
| Hereditary Angioedema Agents | Cinryze, Haegarda, Berinert: [C1 Inhibitor (Human)], Ruconest [C1 Inhibitor (Recombinant)], Takhzyro (lanadelumab-flyo), Icatibant (Firazyr, Sajazir), Kalbitor (ecallantide) | NJ CAID-0034 | J0593, J0596, J0597, J0598, J1290, J1744, J0599 |
| Increlex (mecasermin) | Increlex (mecasermin) | NJ CAID-0045 | J2170 |
| Interleukin-1 Inhibitors | Arcalyst (rilonacept), Ilaris (canakinumab,; Kineret (anakinra) | NJ CAID-0064 | J2793, J0638, J3490, J3590 |
| Mepsevii (vestronidase alfa) | Mepsevii (vestronidase alfa) | NJ CAID-0013 | J3397 |
| Naglazyme (galsulfase) | Naglazyme (galsulfase) | NJ CAID-0023 | J1458, S9357 |
| Onpattro (patisiran) | Onpattro (patisiran) | NJ CAID-0082 | J0222 |
| Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors | Praluent (alirocumab), Repatha (evolocumab) | NJ CAID-0010 | C9399, J3490, J3590 |
| Spravato (esketamine) | Spravato (esketamine) | NJ CAID-0086 | G2082, G2083, S0013 |
| Strensiq (asfotase alfa) | Strensiq (asfotase alfa) | NJ CAID-0079 | J3490 |
| Tegsedi (inotersen) | Tegsedi (inotersen) | NJ CAID-0084 | J3490, C9399 |
| Vimizim (elosulfase alfa) | Vimizim (elosulfase alfa) | NJ CAID-0022 | J1322, S9357 |
| Vyondys 53 (golodirsen) | Vyondys 53 (golodirsen) | NJ CAID-0152 | J1429 |
(Note: in the case of a clinical criteria document being listed on both sites, please utilize those listed directly above.)
If you have questions or feedback, please contact druglist@carelon.com.