Policy UpdatesSimply Healthcare Plans, Inc. - Medicare AdvantageFebruary 27, 2025

Clinical Criteria updates

Effective March 28, 2025

Summary: The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Simply. These policies were developed, revised or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: newly published criteria
  • Revised: addition or removal of medical necessity requirements, new document number

Please share this notice with other members of your practice and office staff.

Please note:

  • The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by Simply only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective Date

Clinical Criteria Number

Clinical Criteria Title

New or Revised

March 28, 2025

CC-0274

Bizengri (zenocutuzumab-zbco)

New

March 28, 2025

CC-0275

Ziihera (zanidatamab-hrii)

New

March 28, 2025

CC-0276

Tryngolza (olezarsen)

New

March 28, 2025

CC-0072

Vascular Endothelial Growth Factor (VEGF) Inhibitors

Revised

March 28, 2025

CC-0185

Oxlumo (lumasiran)

Revised

March 28, 2025

CC-0198

Relizorb (immobilized lipase) cartridge

Revised

March 28, 2025

CC-0256

Rivfloza (nedosiran)

Revised

March 28, 2025

CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

March 28, 2025

CC-0063

Ustekinumab Agents (Stelara, Selarsdi, Imuldosa, Pyzchiva, Otulfi, Wezlana, Yesintek)

Revised

March 28, 2025

CC-0058

Bynfezia Pen, Sandostatin, or Sandostatin LAR (Octreotide) / Octreotide Agents

Revised

March 28, 2025

CC-0130

Imfinzi (durvalumab)

Revised

March 28, 2025

CC-0094

Pemetrexed

Revised

March 28, 2025

CC-0003

Immunoglobulins

Revised

Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal.

FLSMPLY-CR-077228-25-CPN76946

PUBLICATIONS: April 2025 Provider Newsletter