Clinical Criteria updates for specialty pharmacy
The Empire BlueCross BlueShield (Empire) 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 September 22, 2022, clinical criteria meeting. To access the Clinical Criteria information, please visit this link.
Revised Clinical Criteria effective March 1, 2023
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-0002: Colony Stimulating Factor Agents
- ING-CC-0018: Pompe Disease [Lumizyme (alglucosidase alfa), Nexviazyme (avalglucosidase alfa-ngpt)]
- ING-CC-0072: Vascular Endothelial Growth Factor (VEGF) Inhibitors
- ING-CC-0081: Crysvita (burosumab-twza)
- ING-CC-0107: Bevacizumab for Non-Ophthalmologic Indications
The following Clinical Criteria were revised with coding updates This will result in the review of claims for certain diagnoses to determine whether the service meets medical necessity criteria and may result in a not medically necessary determination for certain services:
- ING-CC-0022: Vimizim (elosulfase alfa)
- ING-CC-0202: Saphnelo (anifrolumab-fnia)
December 2022 Newsletter