Products & Programs PharmacyCommercialSeptember 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 June 12, 2023, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective December 1, 2023

The following Clinical Criteria are new:

•    CC-0241 Elfabrio (pegunigalsidase alfa-iwxj)

•    CC-0242 Epkinly (epcoritamab-bysp)

•    CC-0243 Vyjuvek (beremagene geperpavec)

Revised Clinical Criteria effective December 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-0015 Infertility and HCG Agents

•    CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications

•    CC-0062 Tumor Necrosis Factor Antagonists

•    CC-0177 Zilretta (triamcinolone acetonide extended-release)

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

NYBCBS-CM-034114-23-SRS34114

PUBLICATIONS: September 2023 Provider Newsletter