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 May 15, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised Clinical Criteria effective May 28, 2020

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

  • ING-CC-0031 Intravitreal Corticosteroid Implants

 

Revised Clinical Criteria effective June 15, 2020

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

  • ING-CC-0042 Monoclonal Antibodies to Interleukin-17
  • ING-CC-0092 Adcetris (brentuximab)
  • ING-CC-0098 Doxorubicin Hydrochloride Liposome
  • ING-CC-0099 Abraxane (paclitaxel, protein bound)
  • ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
  • ING-CC-0111 Nplate (romiplostim)
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0127 Darzalex (daratumumab)
  • ING-CC-0128 Tecentriq (atezolizumab)

 

Revised Clinical Criteria effective June 15, 2020

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

  • ING-CC-0045 Increlex (mecasermin)
  • ING-CC-0069 Egrifta (tesamorelin)
  • ING-CC-0114 Jevtana (cabazitaxel)
  • ING-CC-0116 Bendamustine agents
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0137 Cablivi (caplacizumab-yhdp)
  • ING-CC-0142 Somatuline Depot (lanreotide)
  • ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
  • ING-CC-0145 Libtayo (cemiplimab-rwlc)
  • ING-CC-0151 Yescarta (axicabtagene ciloleucel)

 

Revised Clinical Criteria effective July 1, 2020

The following clinical criteria were updated with CPT/HCPCS procedure code updates.

  • ING-CC-0006 Hyaluronan Injections
  • ING-CC-0062 Tumor Necrosis Factor Antagonists
  • ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
  • ING-CC-0075 Rituximab Agents for Non-Oncology Indications
  • ING-CC-0154 Givlaari (givosiran)

 

Revised Clinical Criteria effective October 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-0032 Botulinum Toxin
  • ING-CC-0044 Exondys 51 (eteplirsen)
  • ING-CC-0057 Krystexxa (pegloticase)
  • ING-CC-0068 Growth hormone
  • ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
  • ING-CC-0098 Doxorubicin Hydrochloride Liposome
  • ING-CC-0099 Abraxane (paclitaxel, protein bound)
  • ING-CC-0105 Vectibix (panitumumab)
  • ING-CC-0106 Erbitux (cetuximab)
  • ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0128 Tecentriq (atezolizumab)
  • ING-CC-0134 Provenge (sipuleucel-T)
  • ING-CC-0152 Vyondys 53 (golodirsen)
  • ING-CC-0153 Adakveo (crizanlizumab)

 

New Clinical Criteria effective October 1, 2020

The following clinical criteria are new.

  • ING-CC-0162 Tepezza (teprotumumab-trbw)
  • ING-CC-0163 Durysta (bimatoprost implant)

 

549-0720-PN-NY

 



Featured In:
July 2020 Empire Provider News