Products & Programs PharmacyCommercialMay 1, 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 March 15, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective March 31, 2021

The following clinical criteria are new.

  • ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
  • ING-CC-0192 Cosela (trilaciclib)

 

Revised Clinical Criteria effective March 31, 2021, 2021

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

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

 

Revised Clinical Criteria effective April 26, 2021

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

  • ING-CC-0064 Interleukin-1 Inhibitors
  • ING-CC-0075 Rituxan (rituximab) for Non-Oncologic Indications
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
  • ING-CC-0145 Libtayo (cemiplimab-rwlc)
  • ING-CC-0151 Yescarta (axicabtagene ciloleucel)

 

Revised Clinical Criteria effective April 26, 2021

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

  • ING-CC-0011 Ocrevus (ocrelizumab)
  • ING-CC-0037 Kanuma (sebelipase alfa)
  • ING_CC-0070 Jetrea (ocriplasmin)
  • ING-CC-0087 Gamifant (emapalumab-lzsg)
  • ING-CC-0160 Vyepti (eptinezumab)
  • ING-CC-0182 Agents for Iron Deficiency Anemia

 

Revised Clinical Criteria effective May 1, 2021

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

  • ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

 

Revised Clinical Criteria effective July 1, 2021

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

  • ING-CC-0034 Hereditary Angioedema Agents

 

New Clinical Criteria effective August 1, 2021

The following clinical criteria are new.

  • ING-CC-0193 Evkeeza (evinacumab)
  • ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

 

Revised Clinical Criteria effective August 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-0130 Imfinzi (durvalumab)
  • ING-CC-0145 Libtayo (cemiplimab-rwlc)
  • ING-CC-0159 Scenesse (afamelanotide)

 

The following Clinical Criteria document was endorsed at the April 8, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective April 13, 2021

The following clinical criteria is new.

  • ING-CC-0195 Abecma (idecabtagene vicleucel)

 

1124-0521-PN-NY

 

PUBLICATIONS: May 2021 Newsletter