Clinical Criteria updates for specialty pharmacy are available

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 June 18, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective June 26, 2020

The following clinical criteria are new.

• ING-CC-0165 - Trodelvy (sacituzumab govitecan)

 

Revised Clinical Criteria effective July 20, 2020

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

• ING-CC-0029 Dupixent (dupilumab)
• ING-CC-0042 Monoclonal Antibodies to Interleukin-17
• ING-CC-0061 GnRH Analogs for the Treatment of Non-Oncologic Indications
• ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
• ING-CC-0119 Yervoy (ipilimumab)
• ING-CC-0125 Opdivo (nivolumab)
• ING-CC-0128 Tecentriq (atezolizumab)

 

Revised Clinical Criteria effective July 20, 2020

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

• ING-CC-0076 Nulojix (belatacept)
• ING-CC-0136 Drug Dosage, Frequency, and Route of Administration
• ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use

 

Revised Clinical Criteria effective August 1, 2020

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

• ING-CC-0043 Monoclonal Antibodies to Interleukin-5

 

Revised Clinical Criteria effective October 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

 

New Clinical Criteria effective November 1, 2020

The following clinical criteria are new.

• ING-CC-0164 Jelmyto (mitomycin gel)

 

Revised Clinical Criteria effective November 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-0011 Ocrevus (ocrelizumab)
• ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
• ING-CC-0061 GnRH Analogs for the Treatment of Non-Oncologic Indications
• ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

 

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