Products & Programs PharmacyCommercialOctober 31, 2019

Clinical Criteria updates for specialty pharmacy are available

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

The following Clinical Criteria documents were endorsed at the August 16, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

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.

 

New Clinical Criteria effective September 23, 2019

The following clinical criteria are new.

  • ING-CC-0142 Somatuline Depot (lanreotide)
  • ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)

 

Revised Clinical Criteria effective September 23, 2019

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

  • ING-CC-0011 Ocrevus (ocrelizumab)
  • ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
  • ING-CC-0027 Denosumab Agents
  • ING-CC-0029 Dupixent (dupilumab)
  • ING-CC-0030 Implantable and ER Buprenorphine Containing Agents
  • ING-CC-0038 Human Parathyroid Hormone Agents
  • ING-CC-0105 Vectibix (panitumumab)
  • ING-CC-0114 Jevtana (cabazitaxel)
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0127 Darzalex (daratumumab)
  • ING-CC-0128 Tecentriq (atezolizumab)
  • ING-CC-0134 Provenge (sipuleucel-T)

 

Revised Clinical Criteria effective September 23, 2019

The following current 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-0008 Subcutaneous Hormonal Implants
  • ING-CC-0009 Lemtrada (alemtuzumab)
  • ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
  • ING-CC-0020 Tysabri (natalizumab)
  • ING-CC-0036 Naltrexone Implantable Pellets
  • ING-CC-0044 Exondys 51 (eteplirsen)
  • ING-CC-0094 Alimta (pemetrexed disodium)
  • ING-CC-0099 Abraxane (paclitaxel, protein bound)
  • ING-CC-0104 Levoleucovorin Agents
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0129 Bavencio (avelumab)
  • ING-CC-0130 Imfinzi (durvalumab)

 

Revised Clinical Criteria effective October 1, 2019

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

  • ING-CC-0006 Hyaluronan Injections
  • ING-CC-0087 Gamifant
  • ING-CC-0088 Elzonris (tagraxofusp-erzs)

 

Revised Clinical Criteria effective February 1, 2020

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-0002 Colony Stimulating Factor Agents
  • ING-CC-0003 Immunoglobulins
  • ING-CC-0007 Synagis (palivizumab)
  • ING-CC-0013 Mepsevii (vestronidase alfa)
  • ING-CC-0018 Lumizyme (alglucosidase alfa)
  • ING-CC-0021 Fabrazyme (agalsidase beta)
  • ING-CC-0022 Vimizim (elosulfase alfa)
  • ING-CC-0023 Naglazyme (galsulfase)
  • ING-CC-0024 Elaprase (idursufase)
  • ING-CC-0025 Aldurazyme (laronidase)
  • ING-CC-0028 Benlysta (belimumab)
  • ING-CC-0031 Intravitreal Corticosteroid Implants
  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0033 Xolair (omalizumab)
  • ING-CC-0034 Hereditary Angioedema Agents
  • ING-CC-0041 Complement Inhibitors
  • ING-CC-0043 Monoclonal Antibodies to Interleukin-5
  • ING-CC-0048 Spinraza (nusinersen)
  • ING-CC-0050 Monoclonal Antibodies to Interleukin-23
  • ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
  • ING-CC-0058 Octreotide Agents
  • ING-CC-0061 GnRH Analogs for the treatment of non-oncologic indications
  • ING-CC-0062 Tumor Necrosis Factor Antagonists
  • ING-CC-0063 Stelara (ustekinumab)
  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6
  • ING-CC-0071 Entyvio (vedolizumab)
  • ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
  • ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy
  • ING-CC-0075 Rituximab Agents for Non-Oncology Indications
  • ING-CC-0082 Onpattro (patisiran)
  • ING-CC-0106 Erbitux (cetuximab)
  • ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications

 

New Clinical Criteria effective February 1, 2020

The following clinical criteria are new.

  • ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
  • ING-CC-0145 Libtayo (cemiplimab-rwlc)

 

PUBLICATIONS: November 2019 Empire Provider News