Policy Updates Medical Policy & Clinical GuidelinesCommercialApril 30, 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 February 21, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised Clinical Criteria effective March 3, 2020

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

  • ING-CC-0140 Zulresso (brexanolone)

 

Archived Clinical Criteria Effective March 23, 2020

The following clinical criteria document has been archived and its content has been transferred to an existing Pharmacy and Therapeutics (P&T) clinical criteria document.

  • ING-CC-0138 Asparlas (calaspargase pegol-mknl) [Note: Content moved to ING-CC-0096 Asparagine Specific Enzymes]

 

Revised Clinical Criteria effective March 23, 2020

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

  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0090 Ixempra (ixabepilone)
  • ING-CC-0091 Lartruvo (olaratumab)
  • ING-CC-0094 Alimta (pemetrexed disodium)
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0121 Gazyva (obinutuzumab)
  • ING-CC-0123 Cyramza (ramucirumab)
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0130 Imfinzi (durvalumab)
  • ING-CC-0131 Besponsa (inotuzumab ozogamicin)

 

Revised Clinical Criteria effective March 23, 2020

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

  • ING-CC-0044 Exondys 51 (eteplirsen)
  • ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
  • ING-CC-0075 Rituximab Agents for Non-Oncology Indications
  • ING-CC-0085 Actimmune (interferon gamma-1B)
  • ING-CC-0086 Spravato (esketamine) Nasal Spray
  • ING-CC-0089 Mozobil (plerixafor)
  • ING-CC-0096 Asparagine Specific Enzymes [Note: Content for Asparlas (calaspargase pegol-mknl) moved from ING-CC-0138]
  • ING-CC-0103 Faslodex (fulvestrant)
  • ING-CC-0108 Halaven (eribulin)
  • ING-CC-0110 Perjeta (pertuzumab)
  • ING-CC-0113 Sylvant (siltuximab)
  • ING-CC-0115 Kadcyla (ado-trastuzumab)
  • ING-CC-0117 Empliciti (elotuzumab)
  • ING-CC-0120 Kyprolis (carfilzomib)
  • ING-CC-0122 Arzerra (ofatumumab)
  • ING-CC-0126 Blincyto (blinatumomab)
  • ING-CC-0129 Bavencio (avelumab) injection
  • ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)
  • ING-CC-0152 Vyondys 53 (golodirsen)

 

Revised Clinical Criteria effective May 1, 2020

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

  • ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

 

Revised Clinical Criteria effective July 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-0078 Orencia (abatacept)

 

New Clinical Criteria effective August 1, 2020

The following clinical criteria are new.

  • ING-CC-0155 Ethyol (amifostine)
  • ING-CC-0156 Reblozyl (luspatercept)
  • ING-CC-0157 Padcev (enfortumab vedotin)
  • ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
  • ING-CC-0159 Scenesse (afamelanotide)
  • ING-CC-0160 Vyepti (eptinezumab-jjmr)

 

Revised Clinical Criteria effective August 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-0002 Colony Stimulating Factor Agents
  • ING-CC-0015 Infertility and HCG Agents
  • ING-CC-0033 Xolair (omalizumab)
  • ING-CC-0038 Human Parathyroid Hormone Agents
  • ING-CC-0043 Monoclonal Antibodies to Interleukin-5
  • ING-CC-0049 Radicava (edaravone)
  • ING-CC-0062 Tumor Necrosis Factor Antagonists
  • ING-CC-0088 Elzonris (tagraxofusp-erzs)
  • ING-CC-0094 Alimta (pemetrexed disodium)
  • ING-CC-0099 Abraxane (paclitaxel, protein bound)
  • ING-CC-0109 Zaltrap (ziv-aflibercept)
  • ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)
  • ING-CC-0118 Radioimmunotherapy: Zevalin; azedra; Lutathera
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0123 Cyramza (ramucirumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0135 Melanoma Vaccines

 

Coding Updates

As a result of coding updates in the claims system, the claim system edits for the clinical criteria listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination.

 

Effective August 15, 2020, we will be implementing coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.

  • ING-CC-0027 Denusumab Agents

 

418-0520-PN-NY

 

PUBLICATIONS: May 2020 Empire Provider News