Clinical Criteria updates

Summary: On February 25, 2022, and March 24, 2022, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus (Empire). 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
• 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.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Empire only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

 

Effective date	Document number	Clinical Criteria title	New or revised
September 10, 2022	ING-CC-0214	Carvykti (ciltacabtagene autoleucel)	New
September 10, 2022	ING-CC-0125	Opdivo (nivolumab)	Revised
September 10, 2022	ING-CC-0194	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	Revised
September 10, 2022	ING-CC-0010	Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors	Revised
September 10, 2022	ING-CC-0072	Vascular Endothelial Growth Factor (VEGF) Inhibitors	Revised
September 10, 2022	ING-CC-0029	Dupixent (dupilumab)	Revised
September 10, 2022	ING-CC-0208	Adbry (tralokinumab)	Revised

 

NYBCBS-CAID-000459-22-CPN114 August 2022