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 a Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised Clinical Criteria effective August 1, 2021

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

• ING-CC-0008 Subcutaneous Hormonal Implants
• ING-CC-0012 Brineura (cerliponase alfa)
• ING-CC-0013 Mepsevii (vestronidase alfa)
• ING-CC-0017 Xiaflex (collagenase clostridium histolyticum)
• ING-CC-0018 Lumizyme (alglucosidase alfa)
• ING-CC-0021 Fabrazyme (agalsidase beta)
• ING-CC-0022 Vimizim (elosulfase alfa)
• ING-CC-0023 Naglazyme (galsulfase)
• ING-CC-0024 Elaprase (idursufase)
• ING-CC-0025 Aldurazyme (laronidase)
• ING-CC-0028 Benlysta (belimumab)
• ING-CC-0029 Dupixent (dupilumab)
• ING-CC-0033 Xolair (omalizumab)
• ING-CC-0034 Hereditary Angioedema Agents
• ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
• ING-CC-0041 Complement Inhibitors
• ING-CC-0044 Exondys 51 (eteplirsen)
• ING-CC-0049 Radicava (edaravone)
• ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
• ING-CC-0070 Jetrea (ocriplasmin)
• ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy
• ING-CC-0077 Palynziq (pegvaliase-pqpz)
• ING-CC-0079 Strensiq (asfotase alfa)
• ING-CC-0081 Crysvita (burosumab-twza)
• ING-CC-0082 Onpattro (patisiran)
• ING-CC-0148 Agents for Hemophilia B
• ING-CC-0152 Vyondys 53 (golodirsen)
• ING-CC-0156 Reblozyl (luspatercept)
• ING-CC-0159 Scenesse (afamelanotide)
• ING-CC-0170 Uplizna (inebilizumab-cdon)
• ING-CC-0172 Viltepso (viltolarsen)
• ING-CC-0173 Enspryng (satralizumab-mwge)
• ING-CC-0188 Imcivree (setmelanotide)

 

1164-0621-PN-NY