Jan 1, 2021 • Products & Programs / Pharmacy

Empire BlueCross BlueShield’s (“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 November 20, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised Clinical Criteria effective December 3, 2020

The following current clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0119 - Yervoy (ipilimumab)
  • ING-CC-0125 - Opdivo (nivolumab)

 

Revised Clinical Criteria effective December 9, 2020

The following current clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0011 - Ocrevus (ocrelizumab)
  • ING-CC-0174 - Kesimpta (ofatumumab)

 

Revised Clinical Criteria effective December 21, 2020

The following current clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0003 – Immunoglobulins
  • ING-CC-0034 - Hereditary Angioedema Agents
  • ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
  • ING-CC-0062 - Tumor Necrosis Factor Antagonists
  • ING-CC-0063 - Stelara (ustekinumab)
  • ING-CC-0065 - Agents for Hemophilia A and von Willebrand Disease
  • ING-CC-0072 - Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
  • ING-CC-0075 - Rituximab Agents for Non-Oncologic Indications
  • ING-CC-0121 - Gazyva (obinutuzumab)
  • ING-CC-0148 - Agents for Hemophilia B
  • ING-CC-0149 - Select Clotting Agents for Bleeding Disorders

 

Revised Clinical Criteria effective December 21, 2020

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0006 - Hyaluronan Injections
  • ING-CC-0040 - Prialt (ziconotide)
  • ING-CC-0047 - Trogarzo (ibalizumab-uiyk)
  • ING-CC-0049 - Radicava (edaravone)
  • ING-CC-0074 - Akynzeo (fosnetupitant and palonosetron) for injection
  • ING-CC-0107 - Bevacizumab for Non-Ophthalmologic Indications
  • ING-CC-0133 - Aliqopa (copanlisib)
  • ING-CC-0150 - Kymriah (tisagenlecleucel)
  • ING-CC-0151 - Yescarta (axicabtagene ciloleucel)
  • ING-CC-0155 - Ethyol (amifostine)
  • ING-CC-0166 - Trastuzumab Agents Step Therapy
  • ING-CC-0167 - Rituximab Agents for Oncologic Indications Step Therapy
  • ING-CC-0173 - Enspryng (satralizumab-mwge)

 

Revised Clinical Criteria effective January 1, 2021

The following clinical criteria was reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0001 - Erythropoiesis Stimulating Agents

 

Revised Clinical Criteria effective February 1, 2021

The following clinical criteria was reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0014 - Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

 

New Clinical Criteria effective April 1, 2021

The following clinical criteria is new.

  • ING-CC-0183 Sogroya (somapacitan-beco)

 

Revised Clinical Criteria effective April 1, 2021

The following current 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-0003 – Immunoglobulins
  • ING-CC-0011 - Ocrevus (ocrelizumab)
  • ING-CC-0027 - Denosumab Agents
  • ING-CC-0034 - Hereditary Angioedema Agents
  • ING-CC-0039 - GamaSTAN [immune globulin (human)]
  • ING-CC-0041 - Complement Inhibitors
  • ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
  • ING-CC-0048 - Spinraza (nusinersen)
  • ING-CC-0050 - Monoclonal Antibodies to Interleukin-23
  • ING-CC-0062 - Tumor Necrosis Factor Antagonists
  • ING-CC-0063 - Stelara (ustekinumab)
  • ING-CC-0064 - Interleukin-1 Inhibitors
  • ING-CC-0066 - Monoclonal Antibodies to Interleukin-6
  • ING-CC-0071 - Entyvio (vedolizumab)
  • ING-CC-0073 - Alpha-1 Proteinase Inhibitor Therapy
  • ING-CC-0078 - Orencia (abatacept)
  • ING-CC-0121 - Gazyva (obinutuzumab)
  • ING-CC-0148 - Agents for Hemophilia B
  • ING-CC-0149 - Select Clotting Agents for Bleeding Disorders
  • ING-CC-0174 - Kesimpta (ofatumumab)

 

926-0121-PN-NY

 


Featured In:
January 2021 Empire Provider News