Clinical Criteria updates for specialty pharmacy

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 September 22, 2022, clinical criteria meeting. To access the Clinical Criteria information, please visit this link.

 

Coding updates

 

Revised Clinical Criteria effective March 1, 2023

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-0018: Pompe Disease [Lumizyme (alglucosidase alfa), Nexviazyme (avalglucosidase alfa-ngpt)]
• ING-CC-0072: Vascular Endothelial Growth Factor (VEGF) Inhibitors
• ING-CC-0081: Crysvita (burosumab-twza)
• ING-CC-0107: Bevacizumab for Non-Ophthalmologic Indications

 

The following Clinical Criteria were revised with coding updates This will result in the review of claims for certain diagnoses to determine whether the service meets medical necessity criteria and may result in a not medically necessary determination for certain services:

• ING-CC-0022: Vimizim (elosulfase alfa)
• ING-CC-0202: Saphnelo (anifrolumab-fnia)

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

 

NYBCBS-CM-012399-22