Clinical Criteria updates for specialty pharmacy

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 August 20, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised Clinical Criteria effective September 1, 2021

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

• ING-CC-0007 Synagis (palivizumab)

 

Revised Clinical Criteria effective September 1, 2021

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

• ING-CC-0020 Tysabri (natalizumab)
• ING-CC-0062 Tumor Necrosis Factor Antagonists
• ING-CC-0124 Keytruda (pembrolizumab)

 

Revised Clinical Criteria effective September 20, 2021

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

• ING-CC-0001 Erythropoiesis Stimulating Agents
• ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
• ING-CC-0038 Human Parathyroid Hormone Agents
• ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
• ING-CC-0104 Levoleucovorin Agents
• ING-CC-0169 Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
• ING-CC-0193 Evkeeza (evinacumab)

 

Revised Clinical Criteria effective September 20, 2021

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

• ING-CC-0004 H.P. Acthar Gel (repository corticotropin injection)
• ING-CC-0011 Ocrevus (ocrelizumab)
• ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
• ING-CC-0030 Implantable and ER Buprenorphine Containing Agents
• ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
• ING-CC-0036 Naltrexone Implantable Pellets
• ING-CC-0044 Exondys 51 (eteplirsen)
• ING-CC-0058 Octreotide Agents
• ING-CC-0082 Onpattro (patisiran)
• ING-CC-0100 Istodax (romidepsin)
• ING-CC-0139 Evenity (romosozumab-aqqg)
• ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)
• ING-CC-0152 Vyondys 53 (golodirsen)
• ING-CC-0167 Rituximab Agents for Oncologic Indications Step Therapy
• ING-CC-0172 Viltepso (viltolarsen)
• ING-CC-0174 Kesimpta (ofatumumab)
• ING-CC-0176 Beleodaq (belinostat)
• ING-CC-0179 Blenrep (belantamab mafodotin-blmf)
• ING-CC-0180 Monjuvi (tafasitamab-cxix)
• ING-CC-0181 Veklury (remdesivir)
• ING-CC-0189 Amondys 45 (casimersen)
• ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)

 

Revised Clinical Criteria effective October 1, 2021

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

• ING-CC-0100 Istodax (romidepsin)
• ING-CC-0150 Kymriah (tisagenlecleucel)
• ING-CC-0151 Yescarta (axicabtagene ciloleucel)
• ING-CC-0168 Tecartus (brexucabtagene autoleucel)
• ING-CC-0171 Zepzelca (lurbinectedin)
• ING-CC-0173 Enspryng (satralizumab-mwge)
• ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
• ING-CC-0189 Amondys 45 (casimersen)
• ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
• ING-CC-0192 Cosela (trilaciclib)
• ING-CC-0193 Evkeeza (evinacumab)
• ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
• ING-CC-0195 Abecma (idecabtagene vicleucel)
• ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
• ING-CC-0197 Jemperli (dostarlimab)
• ING-CC-0201 Rybrevant (amivantamab-ymjw)

 

Revised Clinical Criteria effective January 1, 2022

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-0001 Erythropoiesis Stimulating Agents
• ING-CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
• ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
• ING-CC-0027 Denosumab Agents
• ING-CC-0029 Dupixent (dupilumab)
• ING-CC-0034 Hereditary Angioedema Agents
• ING-CC-0038 Human Parathyroid Hormone Agents
• ING-CC-0081 Crysvita (burosumab-twza)
• ING-CC-0096 Asparagine Specific Enzymes
• ING-CC-0104 Levoleucovorin Agents
• ING-CC-0156 Reblozyl (luspatercept)
• ING-CC-0182 Agents for Iron Deficiency Anemia

 

New Clinical Criteria effective January 1, 2022

The following clinical criteria are new.

• ING-CC-0202 Saphnelo (anifrolumab-fnia)
• ING-CC-0203 Ryplazim (plasminogen, human-tvmh)

 

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