Products & Programs PharmacyCommercialMarch 31, 2021

Clinical criteria updates for specialty pharmacy

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

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 February 19, 2021 clinical criteria meeting. To access the clinical criteria information please click here.

 

New clinical criteria effective February 25, 2021

The following clinical criteria are new.

  • ING-CC-0186 Margenza (margetuximab-cmkb)
  • ING-CC-0187 Breyanzi (lisocabtagene maraleucel)

 

Revised clinical criteria effective February 25, 2021

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

  • ING-CC-0028 Benlysta (belimumab)
  • ING-CC-0094 Pemetrexed Agents (Alimta, Pemfexy)

 

Revised clinical criteria effective February 25, 2021

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

  • ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
  • ING-CC-0167 Rituximab Agents for Oncologic Indications Step Therapy

 

New clinical criteria effective March 16, 2021

The following clinical criteria are new.

  • ING-CC-0189 Amondys 45 (casimersen)
  • ING-CC-0190 Nulibry (fosdenopterin)

 

Revised clinical criteria effective March 23, 2021

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

  • ING-CC-0033 Xolair (omalizumab)
  • ING-CC-0043 Monoclonal Antibodies to Interleukin-5
  • ING-CC-0099 Abraxane (paclitaxel protein-bound)
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)

 

Revised clinical criteria effective March 23, 2021

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

  • ING-CC-0085 Actimmune (interferon gamma-1b)
  • ING-CC-0088 Elzonris (tagraxofusp-erzs)
  • ING-CC-0089 Mozobil (plerixafor)
  • ING-CC-0090 Ixempra (ixabepilone)
  • ING-CC-0091 Lartruvo (olaratumab)
  • ING-CC-0096 Asparagine Specific Enzymes
  • ING-CC-0103 Faslodex (fulvestrant)
  • ING-CC-0108 Halaven (eribulin)
  • ING-CC-0109 Zaltrap (ziv-aflibercept)
  • ING-CC-0110 Perjeta (pertuzumab)
  • ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)
  • ING-CC-0113 Sylvant (siltuximab)
  • ING-CC-0117 Empliciti (elotuzumab)
  • ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Zevalin)
  • ING-CC-0120 Kyprolis (carfilzomib)
  • ING-CC-0122 Arzerra (ofatumumab)
  • ING-CC-0126 Blincyto (blinatumomab)
  • ING-CC-0129 Bavencio (avelumab) injection
  • ING-CC-0130 Imfinzi (durvalumab)
  • ING-CC-0131 Besponsa (inotuzumab ozogamicin)
  • ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)
  • ING-CC-0135 Melanoma Vaccines
  • ING-CC-0140 Zulresso (brexanolone)
  • ING-CC-0156 Reblozyl (luspatercept)
  • ING-CC-0160 Vyepti (eptinezumab-jjmr)
  • ING-CC-0164 Jelmyto (mitomycin gel)

 

Revised clinical criteria effective April 1, 2021

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

  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0011 Ocrevus (ocrelizumab)
  • ING-CC-0027 Denosumab Agents
  • ING-CC-0121 Gazyva (obinutuzumab)

 

New clinical criteria effective July 1, 2021

The following clinical criteria is new.

  • ING-CC-0188 Imcivree (setmelanotide)

 

Revised clinical criteria effective July 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-0028 Benlysta (belimumab)
  • ING-CC-0033 Xolair (omalizumab)
  • ING-CC-0034 Hereditary Angioedema Agents
  • ING-CC-0043 Monoclonal Antibodies to Interleukin-5
  • ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
  • ING-CC-0075 Rituximab agents for Non-Oncologic Indications
  • ING-CC-0086 Spravato (esketamine) Nasal Spray
  • ING-CC-0094 Pemetrexed Agents (Alimta, Pemfexy)
  • ING-CC-0115 Kadcyla (ado-trastuzumab)
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0123 Cyramza (ramucirumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0157 Padcev (enfortumab vedotin-ejfv)

 

1094-0421-PN-NY

PUBLICATIONS: April 2021 Newsletter