Products & Programs PharmacyCommercialFebruary 29, 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 December 20, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective December 24, 2019

The following clinical criteria are new.

  • ING-CC-0152 Vyondys 53 (golodirsen)

 

New Clinical Criteria effective January 20, 2020

The following clinical criteria are new.

  • ING-CC-0153 Adakveo (crizanlizumab)
  • ING-CC-0154 Givlaari (givosiran)

 

Revised Clinical Criteria effective January 20, 2020

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

  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0099 Abraxane (paclitaxel, protein bound)
  • ING-CC-0128 Tecentriq (atezolizumab)

 

Revised Clinical Criteria effective June 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-0004 H.P. Acthar Gel (repository corticotropin injection)
  • ING-CC-0027 Denosumab Agents

PUBLICATIONS: March 2020 Empire Provider News