Policy Updates Medical Policy & Clinical GuidelinesCommercialSeptember 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 document was endorsed at the August 13, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.


Revised Clinical Criteria effective January 1, 2021

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-0048 Spinraza (nusinersen)

 

The following Clinical Criteria documents were endorsed at the August 21, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective September 1, 2020

The following clinical criteria are new.

  • ING-CC-0169 Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
  • ING-CC-0172 Viltepso (viltolarsen)
  • ING-CC-0173 Enspryng (satralizumab-mwge)

 

Revised Clinical Criteria effective September 1, 2020

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

  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0129 Bavencio (avelumab) injection

 

Revised Clinical Criteria effective October 1, 2020

The following clinical criteria were updated with new procedure and/or diagnosis codes.

  • ING-CC-0094 Alimta (pemetrexed disodium)
  • ING-CC-0100 Istodax (romidepsin)
  • ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
  • ING-CC-0140 Zulresso (brexanolone)
  • ING-CC-0160 Vyepti (eptinezumab-jjmr)
  • ING-CC-0161 Sarclisa (isatuximab-irfc)
  • ING-CC-0162 Tepezza (teprotumumab-trbw)
  • ING-CC-0163 Durysta (bimatoprost implant)
  • ING-CC-0165 Trodelvy (sacituzumab govitecan)

 

Revised Clinical Criteria effective January 1, 2021

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-0094 Alimta (pemetrexed disodium)
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0125 Opdivo (nivolumab)

 

New Clinical Criteria effective January 1, 2021

  • The following clinical criteria are new.
  • ING-CC-0168 Tecartus (brexucabtagene autoleucel)
  • ING-CC-0170 Uplizna (inebilizumab-cdon)
  • ING-CC-0171 Zepzelca (lurbinectedin)

 

Coding Updates

As a result of coding updates in the claims system, the claim system edits for the Clinical Criteria document 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 January 1, 2021, we will be implementing coding updates in the claims system for the following Clinical Criteria document listed below which may result in not medically necessary determinations for certain services.

  • ING-CC-0086 Spravato (esketamine) Nasal Spray

 

671-1020-PN-NY

 

PUBLICATIONS: October 2020 Empire Provider News