Products & Programs PharmacyCommercialAugust 1, 2023

Clinical Criteria updates for specialty pharmacy

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

The Empire BlueCross BlueShield (Empire) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by the Medical Specialty Drug Review team of Empire. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc.* a separate company.

The following Clinical Criteria documents were endorsed at the May 19, 2023, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective November 1, 2023

The following Clinical Criteria is new:

  • CC-0240 Zynyz (retifanlimab-dlwr)

Revised Clinical Criteria effective November 1, 2023

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

  • CC-0032 Botulinum Toxin
  • CC-0057 Krystexxa (pegloticase)
  • CC-0068 Growth Hormone
  • CC-0124 Keytruda (pembrolizumab)
  • CC-0125 Opdivo (nivolumab)
  • CC-0225 Tzield (teplizumab-mzwv)

* Carelon Medical Benefits Management, Inc. is an independent company providing some utilization review services on behalf of the health plan.

NYBCBS-CM-028991-23

PUBLICATIONS: August 2023 Provider Newsletter