Posted in BCBS Empire NY, Pharmacy (Various Insurance Payers), Training, Updates

Empire BCBS (NY) Specialty Pharmacy Changes updates for 2021

Reminder #1:

  1. 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.
  2. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.

New Clinical Criteria effective December 22, 2020

The following clinical criteria is new.

  • ING-CC-0184 Danyelza (naxitamab-gqgk)

New Clinical Criteria effective June 1, 2021

The following clinical criteria is new.

  • ING-CC-0185 Oxlumo (lumasiran)

Revised Clinical Criteria Effective 12/22/2020:

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

  • ING-CC-0124 Keytruda (pembrolizumab)

Revised Clinical Criteria effective January 25, 2021

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

  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0015 Infertility and HCG Agents
  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0154 Givlaari (givosiran)

Revised Clinical Criteria effective January 25, 2021

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

  • ING-CC-0079 Strensiq (Asfotase Alfa)
  • ING-CC-0177 Zilretta (triamcinolone acetonide extended-release)

Revised Clinical Criteria effective June 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-0032 Botulinum Toxin
  • ING-CC-0154 Givlaari (givosiran)

Reminder #2:

Effective June 12, 2021, Empire BCBS NY will be implementing coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.

  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6

To view the complete policies, please visit the following links:

  1. Danyelza
  2. Oxlumo
  3. Keytruda
  4. Colony Stimulating Factor Agents
  5. Infertility and HCG Agents
  6. Botulinum Toxin
  7. Givlaari
  8. Strensiq
  9. Zilretta

Author:

My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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