Empire Bluecross Coverage Criteria
- Empire Bluecross prior authorization
- Empire Bluecross timely filing
- All Empire Bluecross policy updates
Latest Empire Bluecross coverage criteria updates14
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-23Tevimbra (tislelizumab-jsgr) Coverage CriteriaThis policy governs medical-necessity and prior-authorization review for intravenous Tevimbra in adults and specified oncology indications. Coverage is subject to diagnosis, disease characteristics, prior therapy, biomarker results, treatment line, performance status, and combination regimen requirements.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Vascular Endothelial Growth Factor (VEGF) Inhibitors — Medical Drug Clinical CriteriaClinical coverage and utilization management criteria for intravitreal vascular endothelial growth factor (VEGF) antagonists (e.g., bevacizumab, ranibizumab, aflibercept, brolucizumab, faricimab) for ophthalmic indications under the medical benefit.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-22Abecma (idecabtagene vicleucel) — Clinical Coverage CriteriaClinical coverage criteria for Abecma (idecabtagene vicleucel), an autologous BCMA-directed CAR T-cell therapy, for adult patients with relapsed or refractory multiple myeloma; intended for use by providers and utilization management staff at Empire Bluecross.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-22Actimmune (interferon gamma-1b) — Clinical Drug Coverage CriteriaClinical drug coverage criteria for Actimmune (interferon gamma-1b) under the member's medical benefit, specifying indications where requests may be approved or denied and applicable coding. Applies to providers seeking prior authorization for members in the plan.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-22Actimmune (interferon gamma-1b) — Medical Drug Clinical CriteriaClinical prior authorization and medical necessity criteria for Actimmune (interferon gamma-1b) under the member's medical benefit, including covered indications, age-based rules, and non‑approved indications; affects providers prescribing/administering Actimmune for Empire Bluecross members.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Medicaid-Approved Preferred Drug List — Coverage CriteriaA Medicaid preferred drug list (PDL) specifying covered outpatient prescription medications, program notes (PA, QL, SP, AL, DO, ST, OTC), and alphabetical drug listings that govern pharmacy benefit coverage for Empire Bluecross Medicaid members in the applicable state.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Adakveo (crizanlizumab) — coverage criteria for sickle cell diseaseClinical criteria for medical-benefit coverage and prior authorization of Adakveo (crizanlizumab) for members with sickle cell disease, including initial and continuation criteria, quantity limits, coding, and documentation expectations.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-12Intravitreal VEGF inhibitors (clinical criteria and coverage)Clinical criteria, coverage stance, step therapy, and quantity limits for intravitreal vascular endothelial growth factor (VEGF) antagonist agents used to treat retinal diseases (e.g., neovascular AMD, DME, RVO, PDR) for Empire Bluecross members.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-23Abecma (idecabtagene vicleucel) CAR-T for multiple myeloma — Clinical coverage criteria and codingClinical coverage criteria and coding for Abecma (idecabtagene vicleucel), an autologous BCMA-directed CAR T-cell therapy for adults with relapsed or refractory multiple myeloma; applies to authorization decisions for Empire Bluecross members and treating providers.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-05-08Specialty pharmacy medical step therapy requirementsDefines new specialty pharmacy codes subject to Empire BlueCross's medical step therapy review for prior authorizations and renewals, affecting providers requesting coverage for listed specialty drugs.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-01-01Clinical Crown LengtheningDefines clinical indications, general criteria, exclusions, and coding guidance for clinical crown lengthening (CDT D4249) as used in dental benefit review and utilization management by the plan.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-01-01Periodontal MaintenanceDefines clinical indications, criteria, and applicable procedure codes for periodontal maintenance as continuing therapeutic care following definitive periodontal therapy; intended for dental providers and utilization reviewers of Empire Bluecross plans.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyClinical Criteria for MAE Coverage — Chapter 1, Part 4 transmittals indexThis section lists transmittals and table-of-contents entries for Clinical Criteria for MAE Coverage (Chapter 1, Part 4), acting as an index of policy topics, transmittal numbers, and effective dates for referenced sub-policies.All Empire Bluecross updates
- Coverage CriteriaClinical/Medical PolicyProvider Confirmation: Special Supplemental Benefits for the Chronically Ill (SSBCI)This form documents provider confirmation that a Medicare Advantage member meets CMS SSBCI eligibility and clinical criteria for one or more chronic-condition supplemental benefits; it is completed and signed by the treating provider and submitted to the payer. Affects providers caring for Medicare Advantage members in the listed states seeking SSBCI benefits.All Empire Bluecross updates
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Tool Description
Search Empire Bluecross coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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