CommercialOctober 1, 2023
Clinical Criteria updates for specialty pharmacy
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
The Empire BlueCross BlueShield (Empire) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by the Medical Specialty Drug Review team of Empire. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc.* a separate company.
The following Clinical Criteria documents were endorsed at the August 18, 2023, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.
New Clinical Criteria effective January 1, 2024
The following Clinical Criteria are new:
- CC-0244 Columvi (glofitamab-gxbm)
- CC-0246 Rystiggo (rozanolixizumab-noli)
- CC-0247 Beyfortus (nirsevimab)
Revised Clinical Criteria effective January 1, 2024
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:
- CC-0007 Synagis (palivizumab)
- CC-0207 Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)
* Carelon Medical Benefits Management, Inc. is an independent company providing some utilization review services on behalf of the health plan.
NYBCBS-CM-038601-23
PUBLICATIONS: October 2023 Provider Newsletter
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