Level of care pre-service clinical review drug list changes effective September 1, 2018

Effective for dates of service on and after September 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy level of care review process.

 

Level of care pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health (AIM), a separate company.

 

View the Clinical Site of Care (Level of Care) drug list and Clinical Site of Care (Level of Care) pre-service clinical review FAQs for more information.

Clinical UM Guideline or Medical Policy	Drug Name	Drug Code
CG-DRUG-05	Mircera®	J0888
CG-DRUG-09	CuvitruTM	J1555
CG-DRUG-16	Zarxio®	Q5101
CG-DRUG-44	Krystexxa®	J2507
CG-DRUG-61	Supprelin LA®	J9226
CG-DRUG-69	Stelara®	J3358
CG-DRUG-78	Fibryga®	J7178
CG-DRUG-78	Rebinyn®	J7195
DRUG.00027	Prialt®	J2278
DRUG.00081	Exondys 51TM	J1428
DRUG.00093	KanumaTM	J2840
DRUG.00095	OcrevusTM	J2350