Specialty pharmacy clinically equivalent drug list expanded effective January 1, 2019

Effective for dates of service on or after January 1, 2019, the following drug codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy clinically equivalent pre-service clinical review process.

Please note: inclusion of NDC code on claims will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

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

 

Medical Policy or Clinical UM Guideline	Drug	HCPCS or CPT Code	NDC Code(s)
CG-DRUG-09	Cuvitru™	J1555	00944-2850-01 00944-2850-02 00944-2850-03 00944-2850-04 00944-2850-05 00944-2850-06 00944-2850-07 00944-2850-08
CG-DRUG-09	Hizentra®	J1559	44206-0451-01 44206-0452-02 44206-0452-04 44206-0455-10
CG-DRUG-09	HyQvia®	J1575	00944-2510-02 00944-2511-02 00944-2512-02 00944-2513-02 00944-2514-02