September 2021 updates for specialty pharmacy are available (MAC)

Material adverse change (MAC)

 

Prior authorization updates

Effective for dates of service on and after December 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

Clinical Criteria	HCPCS or CPT Code(s)	Drug
**ING-CC-0201	J9999	Rybrevant

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Quantity limit updates

Effective for dates of service on and after December 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0050	J3490, J3590	Skyrizi
*ING-CC-0075	Q5123	Riabni

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

1295-0921-PN-GA