Products & Programs PharmacyCommercialDecember 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 September 27, 2023, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective March 1, 2024

The following Clinical Criteria are new:

  • CC-0250 Veopoz (pozelimab-bbfg)
  • CC-0251 Ycanth (cantharidin)

Revised Clinical Criteria effective March 1, 2024

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-0018 Pompe Disease [Lumizyme (alglucosidase alfa), Nexviazyme (avalglucosidase alfa-ngpt), Pombiliti (cipaglucosidase alfa-atga)]
  • CC-0020 Natalizumab Agents (Tysabri, Tyruko)
  • CC-0021 Fabrazyme (agalsidase beta)
  • CC-0046 Zinplava (bezlotoxumab)
  • CC-0068 Growth Hormones
  • CC-0233 Rebyota (fecal microbiota, live — jslm)

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

NYBCBS-CM-044076-23

PUBLICATIONS: December 2023 Provider Newsletter