Clinical Pharmacy Policies

As a wholly owned subsidiary of Anthem, Inc. (Anthem), Empire BlueCross BlueShield Healthplus (Empire) adopted UniCare’s nationally recognized, evidence-based medical policies and clinical utilization management guidelines effective May 1, 2013. These policies are publicly available at Anthem’s UniCare subsidiary website.

The drug coverage policies below are based on medical necessity considerations subject to applicable benefits. The documents below assist with medical necessity coverage decisions, may include state-specific guidance regarding coverage and do not constitute medical advice. Benefit determination is based on the applicable contract language and/or state requirements.

These policies are not a guarantee of coverage. Contract language or state requirements will prevail when there are conflicts with any medication coverage policy. In all cases, Medicaid contracts or Centers for Medicare & Medicaid Services requirements supersede UniCare policy criteria.

If Empire does not manage the pharmacy benefit for your state, please reference the applicable pharmacy benefit manager’s website and/or manual.

As of May 1, 2014, the following policies were effective.