Clinical Criteria updates for specialty pharmacy

Empire BlueCross BlueShield’s (“Empire”) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.

 

The following Clinical Criteria documents were endorsed at the December 18, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective December 22, 2020

The following clinical criteria is new.

• ING-CC-0184 Danyelza (naxitamab-gqgk)

 

Revised Clinical Criteria effective December 22, 2020

The following current clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0124 Keytruda (pembrolizumab)

 

Revised Clinical Criteria effective January 25, 2021

The following current clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0002 Colony Stimulating Factor Agents
• ING-CC-0015 Infertility and HCG Agents
• ING-CC-0032 Botulinum Toxin
• ING-CC-0154 Givlaari (givosiran)

 

Revised Clinical Criteria effective January 25, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

• ING-CC-0079 Strensiq (Asfotase Alfa)
• ING-CC-0177 Zilretta (triamcinolone acetonide extended-release)

 

New Clinical Criteria effective June 1, 2021

The following clinical criteria is new.

• ING-CC-0185 Oxlumo (lumasiran)

 

Revised Clinical Criteria effective June 1, 2021

The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

• ING-CC-0032 Botulinum Toxin
• ING-CC-0154 Givlaari (givosiran)

 

Coding Updates

As a result of coding updates in the claims system, the claim system edits for the clinical criteria listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination.

 

Effective June 12, 2021, we will be implementing coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.

• ING-CC-0066 Monoclonal Antibodies to Interleukin-6

 

1001-0321-PN-NY