Products & Programs PharmacyCommercialAugust 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).*

 

The following Clinical Criteria documents were endorsed at the June 23, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, please visit this link.

 

New Clinical Criteria effective July 6, 2022

The following Clinical Criteria is new:

  • ING-CC-0217 Amvuttra (vutrisiran)

 

Revised Clinical Criteria effective July 25, 2022

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

  • ING-CC-0015 Infertility and HCG Agents
  • ING-CC-0041 Complement Inhibitors
  • ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0150 Kymriah (tisagenlecleucel)

 

Revised Clinical Criteria effective July 25, 2022

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-0049 Radicava (edaravone)
  • ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
  • ING-CC-0076 Nulojix (belatacept)
  • ING-CC-0077 Palynziq (pegvaliase-pqpz)
  • ING-CC-0136 Drug Dosage, Frequency, and Route of Administration
  • ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use
  • ING-CC-0163 Durysta (bimatoprost implant)

 

New Clinical Criteria effective December 1, 2022

The following Clinical Criteria is new:

  • ING-CC-0218 Xipere (triamcinolone acetonide injectable suspension)

 

Revised Clinical Criteria effective December 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-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications

 

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

 

NYBCBS-CM-004800-22

PUBLICATIONS: September 2022 Newsletter