Products & Programs PharmacyCommercialMay 1, 2023

Clinical Criteria updates for specialty pharmacy

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

The Medical Specialty Drug Review team of Empire BlueCross BlueShield will manage the pre-service clinical review of non-oncology specialty pharmacy drugs. Carelon Medical Benefits Management, Inc.,* a separate company, will manage oncology drugs.

The following Clinical Criteria documents were endorsed at the February 24, 2023, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective August 1, 2023

The following Clinical Criteria are new:

  • CC-0230 Adstiladrin (nadofaragene firadenovec-vncg)
  • CC-0233 Rebyota (fecal microbiota, live – jslm)

Revised Clinical Criteria effective August 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:

  • CC-0062 Tumor Necrosis Factor Antagonists
  • CC-0086 Spravato (esketamine) Nasal Spray
  • CC-0096 Asparagine Specific Enzymes
  • CC-0110 Perjeta (pertuzumab)
  • CC-0115 Kadcyla (ado-trastuzumab)
  • CC-0116 Bendamustine agents
  • CC-0119 Yervoy (ipilimumab)
  • CC-0120 Kyprolis (carfilzomib)
  • CC-0128 Tecentriq (atezolizumab)
  • CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

NYBCBS-CM-022601-23

PUBLICATIONS: May 2023 Provider News