Simply 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
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Visit https://providernews.simplyhealthcareplans.com/articles/clinical-criteria-updates-24337
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