Updates for specialty pharmacy are available - August 2021*

*Change to Prior Authorization Requirements

Prior authorization updates

 

Effective for dates of service on and after November 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.

 

Access the Clinical Criteria information 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-0196	J3490 J9999 J3590	Zynlonta
**ING-CC-0197	J3490 J3590 J9999	Jemperli
*ING-CC-0199	J3490 J3590 C9399	Empaveli

* 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 November 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.

 

Access the Clinical Criteria information 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-0199	J3490 J3590 C9399	Empaveli

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

** Oncology use is managed by AIM.

 

1271-0821-PN-CNT