Products & Programs PharmacyCommercialOctober 31, 2020

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.

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.

 

The following Clinical Criteria documents were endorsed at the September 24, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective September 30, 2020

The following clinical criteria are new.

  • ING-CC-0179 Blenrep (belantamab mafodotin-blmf)
  • ING-CC-0180 Monjuvi (tafasitamab-cxix)

 

Revised Clinical Criteria effective September 30, 2020

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

  • ING-CC-0063 Stelara (ustekinumab)
  • ING-CC-0086 Spravato (esketamine) Nasal Spray
  • ING-CC-0128 Tecentriq (atezolizumab)

 

Revised Clinical Criteria effective October 26, 2020

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

  • ING-CC-0081 Crysvita (burosumab-twza)

 

Reviewed Clinical Criteria effective October 26, 2020

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0008 Subcutaneous Hormonal Implants
  • ING-CC-0012 Brineura (cerliponase alfa)
  • ING-CC-0013 Mepsevii (vestronidase alfa)
  • ING-CC-0017 Xiaflex (collagenase clostridium histolyticum)
  • ING-CC-0018 Lumizyme (alglucosidase alfa)
  • ING-CC-0028 Benlysta (belimumab)
  • ING-CC-0046 Zinplava (bezlotoxumab)
  • ING-CC-0062 Tumor Necrosis Factor Antagonists

 

Revised Clinical Criteria effective February 1, 2021

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-0011 Ocrevus (ocrelizumab)
  • ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
  • 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-0160 Vyepti (eptinezumab-jjmr)

 

759-1120-PN-NY

 

 

PUBLICATIONS: November 2020 Empire Provider News