Material Adverse Change (MAC)

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 AIM Specialty Health® (AIM),* a separate company.


The following Clinical Criteria documents were endorsed at the November 18, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.


New Clinical Criteria effective May 1, 2023

The following Clinical Criteria are new:

  • CC-0222 Tecvayli (teclistamab-cqyv)
  • CC-0223 Imjudo (tremelimumab-actl)
  • CC-0224 Pedmark (sodium thiosulfate injection)


Revised Clinical Criteria effective May 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:

  • CC-0003 Immunoglobulins
  • CC-0041 Complement Inhibitors
  • CC-0042 Monoclonal Antibodies to Interleukin-17
  • CC-0050 Monoclonal Antibodies to Interleukin-23
  • CC-0062 Tumor Necrosis Factor Antagonists
  • CC-0063 Stelara (ustekinumab)
  • CC-0064 Interleukin-1 Inhibitors
  • CC-0066 Monoclonal Antibodies to Interleukin-6
  • CC-0071 Entyvio (vedolizumab)
  • CC-0078 Orencia (abatacept)
  • CC-0100 Istodax (romidepsin)
  • CC-0107 Bevacizumab for Non-Ophthalmologic Indications
  • CC-0124 Keytruda (pembrolizumab)
  • CC-0150 Kymriah (tisagenlecleucel)
  • CC-0151 Yescarta (axicabtagene ciloleucel)
  • CC-0168 Tecartus (brexucabtagene autoleucel)
  • CC-0187 Breyanzi (lisocabtagene maraleucel)
  • CC-0195 Abecma (idecabtagene vicleucel)
  • CC-0204 Tivdak (tisotumab vedotin-tftv)
  • CC-0205 Fyarro (siroliumus albumin bound)
  • CC-0214 Carvykti (ciltacabtagene autoleucel)

* AIM Specialty Health is an independent company providing some utilization review services on behalf of the health plan.


Featured In:
February 2023 Newsletter