Medical drug benefit clinical criteria updates – December 2020

On December 18, 2020, and December 22, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following clinical criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. 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 would like 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 members of your practice and office staff.

 

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.

 

Effective date	Document number	Clinical Criteria title	New or revised
April 8, 2021	ING-CC-0185*	Oxlumo (lumasiran)	New
April 8, 2021	ING-CC-0184*	Danyelza (naxitamab-gqgk)	New
April 8, 2021	ING-CC-0154	Givlaari (givosiran)	Revised
April 8, 2021	ING-CC-0124	Keytruda (pembrolizumab)	Revised
April 8, 2021	ING-CC-0002	Colony Stimulating Factor Agents	Revised
April 8, 2021	ING-CC-0032*	Botulinum Toxin	Revised
April 8, 2021	ING-CC-0015	Infertility and HCG Agents	Revised

 

EBSCRNU-0160-21 February 2021517445MUPENMUB