Updates for specialty pharmacy are available - June 2021

Prior authorization updates

 

Effective for dates of service on and after September 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-0191	J3490, J9999, C9399	Pepaxto
**ING-CC-0192	J3490, C9399	Cosela
*ING-CC-0193	J3490, C9399	Evkeeza
*ING-CC-0194	J3490	Cabenuva
*ING-CC-0167	J9999, J3590, C9399	Riabni

* 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 July 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. 

 

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).

 

Inflectra is changing to preferred status effective July 1, 2021. See additional updates below:

 

Clinical Criteria	Status	Drug(s)	HCPCS Codes
ING-CC-0062	Preferred	Inflectra	Q5103
ING-CC-0062	Preferred	Remicade	J1745
ING-CC-0062	Non-preferred	Avsola	Q5121
ING-CC-0062	Non-preferred	Renflexis	Q5104

 

1184-0621-PN-CNT