Products & Programs PharmacyCommercialJuly 31, 2022

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)

 

The Empire BlueCross BlueShield (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 20, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, please go here.

 

Revised Clinical Criteria effective May 20, 2022

The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:

  • ING-CC-0065 — Agents for hemophilia A and Von Willebrand Disease
  • ING-CC-0148 — Agents for hemophilia B

 

New Clinical Criteria effective June 2, 2022

The following Clinical Criteria is new:

  • ING-CC-0216 — Opdualag™ (nivolumab and relatlimab-rmbw)

 

Revised Clinical Criteria effective June 2, 2022

The following Clinical Criteria was revised to expand medical necessity indications or criteria:

  • ING-CC-0194 — Cabenuva® (cabotegravir extended-release; rilpivirine extended-release) injection

 

Revised Clinical Criteria effective June 20, 2022

The following Clinical Criteria were revised to expand medical necessity indications or criteria:

  • ING-CC-0002 — Colony stimulating factor agents
  • ING-CC-0065 — Agents for hemophilia A and Von Willebrand Disease
  • ING-CC-0092 — Adcetris® (brentuximab vedotin)
  • ING-CC-0106 — Erbitux® (cetuximab)
  • ING-CC-0107 — Bevacizumab for non-ophthalmologic indications
  • ING-CC-0116 — Bendamustine agents
  • ING-CC-0124 — Keytruda® (pembrolizumab)
  • ING-CC-0143 — Polivy® (polatuzumab vedotin-piiq)
  • ING-CC-0145 — Libtayo® (cemiplimab-rwlc)
  • ING-CC-0151 — Yescarta® (axicabtagene ciloleucel)

 

Revised Clinical Criteria effective June 20, 2022

The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:

  • ING-CC-0045 — Increlex® (mecasermin)
  • ING-CC-0057 — Krystexxa® (pegloticase)
  • ING-CC-0069 — Egrifta® (tesamorelin)
  • ING-CC-0098 — Doxorubicin liposome (Doxil®, Lipodox™)
  • ING-CC-0105 — Vectibix® (panitumumab)
  • ING-CC-0111 — Nplate® (romiplostim)
  • ING-CC-0114 — Jevtana® (cabazitaxel)
  • ING-CC-0127 — Darzalex® (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
  • ING-CC-0128 — Tecentriq® (atezolizumab)
  • ING-CC-0134 — Provenge® (sipuleucel-T)
  • ING-CC-0137 — Cablivi (caplacizumab-yhdp)
  • ING-CC-0142 — Somatuline® Depot (lanreotide)
  • ING-CC-0160 — Vyepti® (eptinezumab)
  • ING-CC-0161 — Sarclisa® (isatuximab-irfc)
  • ING-CC-0162 — Tepezza® (teprotumumab-trbw)
  • ING-CC-0165 — Trodelvy® (sacituzumab govitecan)
  • ING-CC-0166 — Trastuzumab agents
  • ING-CC-0169 — Phesgo™ (pertuzumab/trastuzumab/hyaluronidase-zzxf)
  • ING-CC-0178 — Synribo® (omacetaxine mepesuccinate)
  • ING-CC-0188 — Imcivree™ (setmelanotide)
  • ING-CC-0192 — Cosela™ (trilaciclib)
  • ING-CC-0199 — Empaveli® (pegcetacoplan)

 

Revised Clinical Criteria effective July 1, 2022

The following Clinical Criteria were updated with new procedure and/or diagnosis codes:

  • ING-CC-0003 — Immunoglobulins
  • ING-CC-0203 — Ryplazim® (plasminogen, human-tvmh)
  • ING-CC-0205 — Fyarro™ (sirolimus albumin bound)
  • ING-CC-0207 — Vyvgart™ (efgartigimod alfa-fcab)
  • ING-CC-0209 — Leqvio® (inclisiran)
  • ING-CC-0210 — Enjaymo™ (sutimlimab-jome)
  • ING-CC-0211 — Kimmtrak® (tebentafusp-tebn)
  • ING-CC-0212 — Tezspire™ (tezepelumab-ekko)
  • ING-CC-0214 — Carvykti™ (ciltacabtagene autoleucel)

 

Revised Clinical Criteria effective August 1, 2022

The following Clinical Criteria was updated with new procedure and/or diagnosis codes:

  • ING-CC-0072 — Vascular endothelial growth factor (VEGF) inhibitors

 

New Clinical Criteria effective November 1, 2022

The following Clinical Criteria is new:

  • ING-CC-0215 — Ketamine injection (Ketalar®)

 

Revised Clinical Criteria effective November 1, 2022

The following 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-0002 — Colony stimulating factor agents
  • ING-CC-0032 — Botulinum toxin
  • ING-CC-0068 — Growth hormone
  • ING-CC-0087 — Gamifant® (emapalumab-lzsg)
  • ING-CC-0092 — Adcetris (brentuximab vedotin)
  • ING-CC-0107 — Bevacizumab for Non-Ophthalmologic Indications
  • ING-CC-0118 — Radioimmunotherapy and somatostatin receptor targeted radiotherapy (Azedra®, Lutathera®, Pluvicto™, Zevalin®)
  • ING-CC-0119 — Yervoy® (ipilimumab)
  • ING-CC-0124 — Keytruda (pembrolizumab)
  • ING-CC-0145 — Libtayo (cemiplimab-rwlc)
  • ING-CC-0153 — Adakveo® (crizanlizumab)
  • ING-CC-0175 — Proleukin® (aldesleukin)
  • ING-CC-0201 — Rybrevant® (amivantamab-ymjw)

 

The following Clinical Criteria document was endorsed at the June 23, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, please go here.

 

Revised Clinical Criteria effective November 1, 2022

The following 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-0072 — Vascular Endothelial Growth Factor (VEGF) Inhibitors

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield.


NYBCBS-CM-003084-22

PUBLICATIONS: August 2022 Newsletter