Summary: On February 25, 2022, and March 24, 2022, 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. For questions or 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.

 

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

Document number

Clinical Criteria title

New or revised

September 10, 2022

ING-CC-0214

Carvykti (ciltacabtagene autoleucel)

New

September 10, 2022

ING-CC-0125

Opdivo (nivolumab)

Revised

September 10, 2022

ING-CC-0194

Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

Revised

September 10, 2022

ING-CC-0010

Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors

Revised

September 10, 2022

ING-CC-0072

Vascular Endothelial Growth Factor (VEGF) Inhibitors

Revised

September 10, 2022

ING-CC-0029

Dupixent (dupilumab)

Revised

September 10, 2022

ING-CC-0208

Adbry (tralokinumab)

Revised

 

NYBCBS-CAID-000459-22-CPN114 August 2022



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