Products & Programs PharmacyCommercialMay 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 March 26, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised Clinical Criteria effective April 1, 2020

The following clinical criteria were updated with CPT/HCPCS procedure code updates.

ING-CC-0153 Adakveo (crizanlizumab)

ING-CC-0154 Givlaari (givosiran)

 

Revised Clinical Criteria effective April 27, 2020

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

  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0125 Opdivo (nivolumab)

 

Revised Clinical Criteria effective April 27, 2020

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

  • ING-CC-0037 Kanuma (sebelipase alfa)
  • ING-CC-0070 Jetrea (ocriplasmin)
  • ING-CC-0087 Gamifant

 

Revised Clinical Criteria effective September 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-0058 Octreotide Agents

 

New Clinical Criteria effective September 1, 2020

The following clinical criteria are new.

  • ING-CC-0161 Sarclisa (isatuximab-irfc)

 

461-0620-PN-NY

 

PUBLICATIONS: June 2020 Empire Provider News