MedicaidDecember 4, 2023
Clinical Criteria updates — August 2023
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
Summary: On May 19, 2023, August 18, 2023, and August 30, 2023, 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 providers in 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 | Clinical Criteria number | Clinical Criteria title | New or revised |
January 11, 2024 | *CC-0244 | Columvi (glofitamab-gxbm) | New |
January 11, 2024 | *CC-0245 | Izervay (avacincaptad pegol) | New |
January 11, 2024 | *CC-0246 | Rystiggo (rozanolixizumab-noli) | New |
January 11, 2024 | *CC-0247 | Beyfortus (nirsevimab) | New |
January 11, 2024 | CC-0001 | Erythropoiesis Stimulating Agents | Revised |
January 11, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised |
January 11, 2024 | CC-0104 | Levoleucovorin Agents | Revised |
January 11, 2024 | CC-0100 | Romidepsin | Revised |
January 11, 2024 | *CC-0182 | Iron Agents | Revised |
January 11, 2024 | CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised |
January 11, 2024 | CC-0176 | Beleodaq (belinostat) | Revised |
January 11, 2024 | CC-0180 | Monjuvi (tafasitamab-cxix) | Revised |
January 11, 2024 | CC-0107 | Bevacizumab for non-ophthalmologic indications | Revised |
January 11, 2024 | CC-0216 | Opdualag (nivolumab and relatlimab-rmbw) | Revised |
January 11, 2024 | CC-0196 | Zynlonta (loncastuximab tesirine-lpyl) | Revised |
January 11, 2024 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised |
January 11, 2024 | CC-0203 | Ryplazim (plasminogen, human-tvmh) | Revised |
January 11, 2024 | CC-0193 | Evkeeza (evinacumab) | Revised |
January 11, 2024 | *CC-0034 | Hereditary Angioedema Agents | Revised |
January 11, 2024 | *CC-0041 | Complement Inhibitors | Revised |
January 11, 2024 | *CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised |
January 11, 2024 | CC-0028 | Benlysta (belimumab) | Revised |
January 11, 2024 | *CC-0243 | Vyjuvek (beremagene geperpavec) | Revised |
January 11, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
January 11, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised |
January 11, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised |
January 11, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
January 11, 2024 | *CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
January 11, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised |
Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross Blue Shield Association.
NYBCBS-CD-044610-23-CPN44139
PUBLICATIONS: January 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/new-york/articles/clinical-criteria-updates-august-2023-17218-17218
Or scan this QR code with your phone