Clinical Criteria updates for specialty pharmacy

Material Adverse Change (MAC)

 

Empire BlueCross BlueShield’s 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 25, 2022, Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised clinical criteria effective January 1, 2022

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

• ING-CC-0202 Saphnelo (anifrolumab-fnia)

 

Revised clinical criteria effective March 1, 2022

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

• ING-CC-0018 Agents for Pompe Disease

 

New clinical criteria effective March 16, 2022

The following clinical criteria are new.

• ING-CC-0210 Enjaymo (sutimlimab-jome)
• ING-CC-0211 Kimmtrak (tebentafusp-tebn)
• ING-CC-0212 Tezspire (tezepelumab-ekko)
• ING-CC-0213 Voxzogo (vosoritide)

 

Revised clinical criteria effective March 28, 2022

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

• ING-CC-0038 Human Parathyroid Hormone Agents
• ING-CC-0042 Monoclonal Antibodies to Interleukin-17
• ING-CC-0050 Monoclonal Antibodies to Interleukin-23
• ING-CC-0078 Orencia (abatacept)
• ING-CC-0099 Abraxane (paclitaxel, protein bound)
• ING-CC-0108 Halaven (eribulin)
• ING-CC-0110 Perjeta (pertuzumab)
• ING-CC-0115 Kadcyla (ado-trastuzumab)
• ING-CC-0119 Yervoy (ipilimumab)
• ING-CC-0120 Kyprolis (carfilzomib)
• ING-CC-0125 Opdivo (nivolumab)
• ING-CC-0126 Blincyto (blinatumomab)
• ING-CC-0129 Bavencio (avelumab)
• ING-CC-0157 Padcev (enfortumab vedotin)

 

Revised clinical criteria effective March 28, 2022

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

• ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
• ING-CC-0075 Rituximab agents for Non-Oncologic Indications
• ING-CC-0085 Actimmune (interferon gamma-1b)
• ING-CC-0088 Elzonris (tagraxofusp-erzs)
• ING-CC-0089 Mozobil (plerixafor)
• ING-CC-0091 Lartruvo (olaratumab)
• ING-CC-0094 Pemetrexed Agents (Alimta, Pemfexy)
• ING-CC-0096 Asparagine Specific Enzymes
• ING-CC-0103 Faslodex (fulvestrant)
• ING-CC-0109 Zaltrap (ziv-aflibercept)
• ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)
• ING-CC-0113 Sylvant (siltuximab)
• ING-CC-0117 Empliciti (elotuzumab)
• ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Zevalin)
• ING-CC-0121 Gazyva (obinutuzumab)
• ING-CC-0122 Arzerra (ofatumumab)
• ING-CC-0123 Cyramza (ramucirumab)
• ING-CC-0130 Imfinzi (durvalumab)
• ING-CC-0131 Besponsa (inotuzumab ozogamicin)
• ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)
• ING-CC-0135 Melanoma Vaccines
• ING-CC-0140 Zulresso (brexanolone)
• ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
• ING-CC-0164 Jelmyto (mitomycin gel)
• ING-CC-0167 Rituximab Agents for Oncologic Indications
• ING-CC-0177 Zilretta (triamcinolone acetonide extended-release)
• ING-CC-0182 Iron Agents
• ING-CC-0205 Fyarro (sirolimus albumin bound)

 

Revised clinical criteria effective April 1, 2022

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

• ING-CC-0018 Agents for Pompe Disease
• ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
• ING-CC-0202 Saphnelo (anifrolumab-fnia)
• ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
• ING-CC-0204 Tivdak (tisotumab vedotin-tftv)
• ING-CC-0205 Fyarro (sirolimus albumin bound)

 

Revised clinical criteria effective May 1, 2022

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

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

 

Revised clinical criteria effective August 1, 2022

The following 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-0033 Xolair (omalizumab)
• ING-CC-0043 Monoclonal Antibodies to Interleukin-5
• ING-CC-0062 Tumor Necrosis Factor Antagonists
• ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
• ING-CC-0078 Orencia (abatacept)
• ING-CC-0086 Spravato (esketamine) Nasal Spray
• ING-CC-0090 Ixempra (ixabepilone)
• ING-CC-0099 Abraxane (paclitaxel, protein bound)
• ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
• ING-CC-0124 Keytruda (pembrolizumab)
• ING-CC-0166 Trastuzumab Agents
• ING-CC-0186 Margenza (margetuximab-cmkb)
• ING-CC-0209 Leqvio (inclisiran)

 

The following clinical criteria documents were endorsed at the March 24, 2022, Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New clinical criteria effective April 4, 2022

The following clinical criteria is new.

• ING-CC-0214 Carvykti (Ciltacabtagene autoleucel)

 

Revised clinical criteria effective April 4, 2022

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

• ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

 

Revised clinical criteria effective April 25, 2022

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

• ING-CC-0125 Opdivo (nivolumab)

 

Revised clinical criteria effective April 25, 2022

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-0159 Scenesse (afamelanotide) ING-CC-0167 Rituximab Agents for Oncologic Indications
• ING-CC-0182 Iron Agents

 

Revised clinical criteria effective May 1, 2022

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

• ING-CC-0075 Rituximab Agents for Non-Oncologic Indications

 

Revised clinical criteria effective August 1, 2022

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

• ING-CC-0166 Trastuzumab Agents

 

Revised clinical criteria effective August 1, 2022

The following 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-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
• ING-CC-0029 Dupixent (dupilumab)
• ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
• ING-CC-00208 Adbry (tralokinumab)

 

2151-0522-PN-NY