State & FederalMedicare AdvantageFebruary 28, 2022

Clinical Criteria updates

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

On September 22, 2021, and November 19, 2021, the Pharmacy and Therapeutics (P&T) committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. 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.

 

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

 

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

March 9, 2022

*ING-CC-0204

Tivdak (tisotumab vedotin-tftv)

New

March 9, 2022

*ING-CC-0018

Lumizyme (alglucosidase alfa); Nexviazyme (avalglucosidase alfa-ngpf)

Revised

March 9, 2022

*ING-CC-0128

Tecentriq (atezolizumab)

Revised

March 9, 2022

*ING-CC-0012

Brineura (cerliponase alfa)

Revised

March 9, 2022

*ING-CC-0021

Fabrazyme (agalsidase beta)

Revised

March 9, 2022

*ING-CC-0017

Xiaflex (collagenase clostridium histolyticum)

Revised

March 9, 2022

*ING-CC-0026

Testosterone Injectable

Revised

March 9, 2022

*ING-CC-0100

Istodax (romidepsin)

Revised

March 9, 2022

*ING-CC-0125

Opdivo (nivolumab)

Revised

March 9, 2022

ING-CC-0197

Jemperli (dostarlimab-gxly)

Revised

March 9, 2022

ING-CC-0124

Keytruda (pembrolizumab)

Revised

March 9, 2022

*ING-CC-0061

GnRH Analogs for the Treatment of Non-Oncologic Indications

Revised

March 9, 2022

*ING-CC-0148

Agents for Hemophilia B

Revised

March 9, 2022

*ING-CC-0149

Select Clotting Agents for Bleeding Disorders

Revised

March 9, 2022

*ING-CC-0065

Agents for Hemophilia A and von Willebrand Disease

Revised

March 9, 2022

ING-CC-0168

Tecartus (brexucabtagene autoleucel)

Revised

March 9, 2022

*ING-CC-0195

Abecma (idecabtagene vicleucel)

Revised

March 9, 2022

*ING-CC-0001

Erythropoiesis Stimulating Agents

Revised

March 9, 2022

*ING-CC-0173

Enspryng (satralizumab-mwge)

Revised

March 9, 2022

*ING-CC-0170

Uplizna (inebilizumab-cdon)

Revised

March 9, 2022

*ING-CC-0041

Complement Inhibitors

Revised

March 9, 2022

*ING-CC-0071

Entyvio (vedolizumab)

Revised

March 9, 2022

*ING-CC-0064

Interleukin-1 Inhibitors

Revised

March 9, 2022

*ING-CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

March 9, 2022

*ING-CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

March 9, 2022

*ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

March 9, 2022

*ING-CC-0078

Orencia (abatacept)

Revised

March 9, 2022

*ING-CC-0063

Stelara (ustekinumab)

Revised

March 9, 2022

*ING-CC-0062

Tumor Necrosis Factor Antagonists

Revised

March 9, 2022

ING-CC-0003

Immunoglobulins

Revised

March 9, 2022

*ING-CC-0049

Radicava (edaravone)

Revised

March 9, 2022

*ING-CC-0075

Rituximab Agents for Non-Oncologic Indications

Revised

March 9, 2022

*ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Revised

March 9, 2022

ING-CC-0107

Bevacizumab for Non-Ophthalmologic Indications

Revised

March 9, 2022

ING-CC-0106

Erbitux (cetuximab)

Revised

March 9, 2022

ING-CC-0105

Vectibix (panitumumab)

Revised

March 9, 2022

ING-CC-0043

Monoclonal Antibodies to Interleukin-5

Revised

March 9, 2022

*ING-CC-0068

Growth Hormone

Revised

 

EBSCRNU-0216-22 January 2022

 

PUBLICATIONS: March 2022 Newsletter