Clinical Criteria updates for specialty pharmacy are available

The following Clinical Criteria documents were endorsed at the September 19, 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.

 

Revised Clinical Criteria effective October 14, 2019

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

• ING-CC-0015 Infertility Agents

 

Revised Clinical Criteria effective October 14, 2019

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

• ING-CC-0017 Xiaflex (collagenase clostridium histolyticum)
• ING-CC-0046 Zinplava (bezlotoxumab)
• ING-CC-0081 Crysvita (burosumab-twza)

 

Revised Clinical Criteria effective February 1, 2019

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

• 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-0058 Octreotide Agents

 

Revised Clinical Criteria effective March 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-0012 Brineura (cerliponase alfa)
• ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists