Products & Programs PharmacyCommercialJune 30, 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 May 21, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective June 5, 2021

The following clinical criteria is new.

  • ING-CC-0199 - Empaveli (pegcetacoplan)

 

Revised Clinical Criteria effective June 21, 2021

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

  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0062 Tumor Necrosis Factor Antagonists
  • ING-CC-0064 Interleukin-1 inhibitors
  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6
  • ING-CC-0098 Doxorubicin Liposome (Doxil, Lipodox)
  • ING-CC-0099 Abraxane (paclitaxel, protein bound)
  • ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
  • ING-CC-0111 Nplate (romiplostim)
  • ING-CC-0120 Kyprolis (carfilzomib)
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
  • ING-CC-0128 Tecentriq (atezolizumab)
  • ING-CC-0142 Somatuline Depot (lanreotide)
  • ING-CC-0150 Kymriah (tisagenlecleucel)
  • ING-CC-0151 Yescarta (axicabtagene ciloleucel)
  • ING-CC-0160 Vyepti (eptinezumab)
  • ING-CC-0161 Sarclisa (isatuximab-irfc)
  • ING-CC-0163 Durysta (bimatoprost implant)
  • ING-CC-0165 Trodelvy (sacituzumab govitecan)

 

Revised Clinical Criteria effective June 21, 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-0045 Increlex (mecasermin)
  • ING-CC-0057 Krystexxa (pegloticase)
  • ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • ING-CC-0068 Growth Hormone
  • ING-CC-0069 Egrifta (tesamorelin)
  • ING-CC-0087 Gamifant (emapalumab-lzsg)
  • ING-CC-0092 Adcetris (brentuximab vedotin)
  • ING-CC-0105 Vectibix (panitumumab)
  • ING-CC-0106 Erbitux (cetuximab)
  • ING-CC-0116 Bendamustine agents
  • ING-CC-0134 Provenge (sipuleucel-T)
  • ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
  • ING-CC-0153 Adakveo (crizanlizumab)
  • ING-CC-0162 Tepezza (teprotumumab-trbw)
  • ING-CC-0166 Trastuzumab Agents
  • ING-CC-0171 Zepzelca (lurbinectedin)
  • ING-CC-0175 Proleukin (aldesleukin)
  • ING-CC-0178 Synribo (omacetaxine mepesuccinate)
  • ING-CC-0183 Sogroya (somapacitan-beco)
  • ING-CC-0192 Cosela (trilaciclib)
  • ING-CC-0195 Abecma (idecabtagene vicleucel)

 

Revised Clinical Criteria effective July 1, 2021

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

  • ING-CC-0125 Opdivo (nivolumab)

 

Revised Clinical Criteria effective July 1, 2021

The following clinical criteria were updated with new procedure and/or diagnosis codes)

  • ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • ING-CC-0075 Rituximab agents for Non-Oncologic Indications
  • ING-CC-0167 Rituximab Agents for Oncologic Indications Step Therapy
  • ING-CC-0184 Danyelza (naxitamab-gqgk)
  • ING-CC-0185 Oxlumo (lumasiran)
  • ING-CC-0186 Margenza (margetuximab-cmkb)
  • ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
  • ING-CC-0189 Amondys 45 (casimersen)
  • ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
  • ING-CC-0192 Cosela (trilaciclib)

 

New Clinical Criteria effective October 1, 2021

The following clinical criteria are new.

  • ING-CC-0196 - Zynlonta (loncastuximab tesirine-lpyl)
  • ING-CC-0197 - Jemperli (dostarlimab)
  • ING-CC-0198 - Relizorb (immobilized lipase) cartridge

 

Revised Clinical Criteria effective October 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-0020 Tysabri (natalizumab)
  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0062 Tumor Necrosis Factor Antagonists
  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6
  • ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
  • ING-CC-0111 Nplate (romiplostim)
  • ING-CC-0114 Jevtana (cabazitaxel)
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0128 Tecentriq (atezolizumab)
  • ING-CC-0137 Cablivi (caplacizumab-yhdp)
  • ING-CC-0145 Libtayo (cemiplimab-rwlc)
  • ING-CC-0160 Vyepti (eptinezumab)

 

1217-0721-PN-NY

 

PUBLICATIONS: July 2021 Newsletter