CommercialOctober 31, 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 a separate company, Carelon Medical Benefits Management, Inc.
The following Clinical Criteria documents were endorsed at the August 18, 2023, Clinical Criteria meeting.
To access the Clinical Criteria information, visit this link.
Revised Clinical Criteria effective February 1, 2024
The following Clinical Criteria were revised and might result in services that were previously covered to no longer be found medically necessary:
- CC-0034 Hereditary Angioedema Agents
- CC-0041 Complement Inhibitors
- CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
- CC-0119 Yervoy (ipilimumab)
- CC-0124 Keytruda (pembrolizumab)
- CC-0125 Opdivo (nivolumab)
- CC-0182 Iron Agents
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
NYBCBS-CM-040818-23
PUBLICATIONS: November 2023 Provider Newsletter
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