MedicaidAugust 25, 2023
Clinical Criteria updates - May 2023
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
On August 19, 2022, September 15, 2022, November 18, 2022, December 22, 2022, May 2, 2023, and May 19, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus (Empire). These policies were developed, revised, or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: Newly published criteria.
- Revised: Addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Please share this notice with other providers in your practice and office staff.
Please note:
- The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Empire only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised |
September 29, 2023 | *CC-0237 | Qalsody (tofersen) | New |
September 29, 2023 | *CC-0238 | Hydroxyprogesterone caproate | New |
September 29, 2023 | *CC-0240 | Zynyz (retifanlimab-dlwr) | New |
September 29, 2023 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised |
September 29, 2023 | CC-0002 | Colony Stimulating Factor Agents | Revised |
September 29, 2023 | CC-0128 | Tecentriq (atezolizumab) | Revised |
September 29, 2023 | CC-0098 | Doxorubicin Liposome (Doxil, Lipodox) | Revised |
September 29, 2023 | CC-0101 | Torisel (temsirolimus) | Revised |
September 29, 2023 | CC-0107 | Bevacizumab for Non-Ophthalmologic Indications | Revised |
September 29, 2023 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised |
September 29, 2023 | CC-0092 | Adcetris (brentuximab vedotin) | Revised |
September 29, 2023 | CC-0095 | Velcade (bortezomib) | Revised |
September 29, 2023 | CC-0105 | Vectibix (panitumumab) | Revised |
September 29, 2023 | CC-0178 | Synribo (omacetaxine mepesuccinate) | Revised |
September 29, 2023 | CC-0114 | Jevtana (cabazitaxel) | Revised |
September 29, 2023 | CC-0145 | Libtayo (cemiplimab-rwlc) | Revised |
September 29, 2023 | *CC-0032 | Botulinum Toxin | Revised |
September 29, 2023 | CC-0068 | Growth Hormone | Revised |
September 29, 2023 | *CC-0057 | Krystexxa (pegloticase) | Revised |
September 29, 2023 | *CC-0125 | Opdivo (nivolumab) | Revised |
September 29, 2023 | *CC-0225 | Tzield (teplizumab-mzwv) | Revised |
September 29, 2023 | *CC-0167 | Rituximab Agents for Oncologic Indications | Revised |
September 29, 2023 | *CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised |
September 29, 2023 | *CC-0182 | Iron Agents | Revised |
September 29, 2023 | *CC-0124 | Keytruda (pembrolizumab) | Revised |
NYBCBS-CD-031930-23-CPN30759
PUBLICATIONS: September 2023 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/new-york/articles/clinical-criteria-updates-may-2023-25-15262
Or scan this QR code with your phone