Products & Programs PharmacyCommercialAugust 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 June 20, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Empire’s prior authorization 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 July 15, 2019

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

  • ING-CC-0124 Keytruda (pembrolizumab)

 

Revised Clinical Criteria effective July 15, 2019

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

  • ING-CC-0008 Subcutaneous Hormonal Implants
  • ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
  • ING-CC-0076 Nulojix (belatacept)
  • ING-CC-0077 Palynziq (pegvaliase-pqpz)

 

Revised Clinical Criteria effective September 1, 2019

The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline

Clinical Criteria

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

CG-DRUG-62

ING-CC-0103

Faslodex (fulvestrant) 

Faslodex

J9395

DRUG.00062

ING-CC-0121

Gazyva (obinutuzumab)

Gazyva

J9301

 

Revised Clinical Criteria effective November 1, 2019

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

  • ING-CC-0048 Spinraza (nusinersen)

 

Revised Clinical Criteria effective December 1, 2019

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-0003 Immunoglobulins
  • ING-CC-0031 Intravitreal Corticosteroid Implants
  • ING-CC-0061 GnRH Analogs for the treatment of non-oncologic indications

PUBLICATIONS: September 2019 Empire Provider News