State & FederalMedicaidOctober 31, 2021

Clinical Criteria updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

On August 21, 2020, November 20, 2020, and June 24, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. If you have questions or need 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
  • Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

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 policy. This does not apply to pharmacy services.

Effective date

Document number

Clinical Criteria title

New or revised

November 1, 2021

*ING-CC-0201

Rybrevant (amivantamab-vmjm)

New

November 1, 2021

*ING-CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

November 1, 2021

*ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

November 1, 2021

ING-CC-0125

Opdivo (nivolumab)

Revised

November 1, 2021

ING-CC-0124

Keytruda (pembrolizumab)

Revised

November 1, 2021

*ING-CC-0102

GnRH Analogs for Oncologic Indications

Revised

November 1, 2021

ING-CC-0076

Nulojix (belatacept)

Revised

November 1, 2021

*ING-CC-0077

Palynziq (pegvaliase-pqpz)

Revised

November 1, 2021

ING-CC-0067

Prostacyclin Infusion and Inhalation Therapy

Revised

November 1, 2021

ING-CC-0194

Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

Revised

November 1, 2021

*ING-CC-0174

Kesimpta (ofatumumab)

Revised

November 1, 2021

*ING-CC-0182

Agents for Iron Deficiency Anemia

Revised


NYE-NU-0352-21 September 2021

PUBLICATIONS: November 2021 Newsletter