Products & Programs PharmacyCommercialAugust 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.

Material adverse change (MAC) notification

 

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 June 24, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective June 30, 2021

The following clinical criteria is new.

  • ING-CC-0201 Rybrevant (amivantamab-ymjw)

 

Revised Clinical Criteria effective June 30, 2021

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

  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0125 Opdivo (nivolumab)

 

Revised Clinical Criteria effective July 26, 2021

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

  • ING-CC-0042 Monoclonal Antibodies to Interleukin-17
  • ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
  • ING-CC-0077 Palynziq (pegvaliase-pqpz)

 

Revised Clinical Criteria effective July 26, 2021

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

  • ING-CC-0031 Intravitreal Corticosteroid Implants
  • ING-CC-0050 Monoclonal Antibodies to Interleukin-23
  • ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
  • ING-CC-0076 Nulojix (belatacept)
  • ING-CC-0136 Drug Dosage, Frequency, and Route of Administration
  • ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use
  • ING-CC-0174 Kesimpta (ofatumumab)
  • ING-CC-0182 Agents for Iron Deficiency Anemia

 

Revised Clinical Criteria effective August 23, 2021

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

  • ING-CC-0182 Agents for Iron Deficiency Anemia

 

Revised Clinical Criteria effective December 1, 2021

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

  • ING-CC-0077 Palynziq (pegvaliase-pqpz)

 

1302-0921-PN-NY

 

PUBLICATIONS: September 2021 Newsletter