The following Clinical Criteria documents were endorsed at the November 15, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

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.

 

Revised Clinical Criteria effective December 16, 2019

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

  • ING-CC-0003 Immunoglobulins
  • ING-CC-0041 Complement Inhibitors
  • ING-CC-0042 Monoclonal Antibodies to Interleukin-17
  • ING-CC-0063 Stelara (ustekinumab)
  • ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
  • ING-CC-0075 Rituximab Agents for Non-Oncology Indications
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0127 Darzalex (daratumumab)
  • ING-CC-0128 Tecentriq (atezolizumab)
  • ING-CC-0133 Aliqopa (copanlisib)

 

Revised Clinical Criteria effective December 16, 2019

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

  • ING-CC-0006 Hyaluronan Injections
  • ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
  • ING-CC-0039 GamaSTAN [(immune globulin (human)]
  • 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-0079 Strensiq (asfotase alfa)
  • ING-CC-0090 Ixempra (ixabepilone)
  • ING-CC-0100 Istodax (romidepsin)
  • ING-CC-0103 Faslodex (fulvestrant)
  • ING-CC-0108 Halaven (eribulin)
  • ING-CC-0110 Perjeta (pertuzumab)
  • ING-CC-0115 Kadcyla (ado-trastuzumab)

 

Revised Clinical Criteria effective February 1, 2020

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

  • ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy

 

Revised Clinical Criteria effective February 5, 2020

The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline

Clinical Criteria

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

MED.00123

ING-CC-0151

Yescarta (axicabtagene ciloleucel)

Yescarta

0537T, 0538T, 0539T, 0540T, Q2041,

XW033C3, XW043C3

 

Revised Clinical Criteria effective February 5, 2020

The following new clinical criteria were revised with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline

Clinical Criteria

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

MED.00124

ING-CC-0150

Kymriah (tisagenlecleucel)

Kymriah

0537T, 0538T, 0539T, 0540T, Q2042,

XW033C3, XW043C3

 

Revised Clinical Criteria effective May 1, 2020

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-0034 Hereditary Angioedema Agents
  • ING-CC-0041 Complement Inhibitors
  • ING-CC-0042 Monoclonal Antibodies to Interleukin-17
  • ING-CC-0043 Monoclonal Antibodies to Interleukin-5
  • 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-0065 Agents for Hemophilia A and von Willebrand Disease. [Note: Content for Agents for Hemophilia B moved to ING-CC-0148 and content for Select Clotting Agents for Bleeding Disorders moved to ING-CC-0149.]
  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6
  • ING-CC-0071 Entyvio (vedolizumab)
  • ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
  • ING-CC-0078 Orencia (abatacept)
  • ING-CC-0150 Kymriah (tisagenlecleucel)

 

Revised Clinical Criteria effective May 1, 2020

The following new clinical criteria were revised with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline

Clinical Criteria

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

ING-CC-0065

ING-CC-0148

Agents for Hemophilia B

Coagulation Factor IX, Human plasma-derived

·         Alphanine SD, Mononine

Factor IX Complex, human plasma-derived

·         Bebulin, Profilnine SD

Factor IX Recombinant

·         Benefix, Ixinity, Rixubis

Coagulation Factor IX-Long-Acting

·         Recombinant, Albumin Fusion Protein--- Idelvion

·         Recombinant coagulation factor IX, Fc Fusion Protein --- Alprolix

·         Recombinant coagulation factor IX, GlycoPEGylated --- Rebinyn

J7193, J7194, J7195, J7200, J7201, J7202, J7203

 

Revised Clinical Criteria effective May 1, 2020

The following new clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline

Clinical Criteria

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

ING-CC-0065

ING-CC-0149

Select Clotting Agents for Bleeding Disorders

Anti-inhibitor Anti-inhibitor Coagulant Complex

· FEIBA

Coagulation Factor X, Human plasma-derived

·         Coagadex

Factor VIIa Recombinant

·         Novoseven RT

Factor XIII

·         Factor XIII Human plasma-derived ---Corifact

·         Factor XIII A subunit Recombinant ---Tretten

Fibrinogen Concentrate

·         Human plasma-derived---RiaSTAP

·         Human fibrinogen ---Fibryga

J7175, J7177, J7178, J7180, J7181 J7189, J7198

             

 



Featured In:
February 2020 Empire Provider News