Updates for specialty pharmacy are available - July 2021*

Prior authorization updates

 

Effective for dates of service on and after October 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.

 

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-0195	J3490 J9999 C9399 J3590	Abecma

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

** Oncology use is managed by AIM.

 

Step therapy updates

 

Effective for dates of service on and after October 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process. 

 

Access the Clinical Criteria information.

 

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

 

Clinical Criteria	HCPCS Code	Status	Drug(s)
ING-CC-0020	J2323	Non-preferred	Tysabri

 

1221-0721-PN-CNT