Specialty pharmacy pre-service clinical review list expanded effective September 1, 2019

Effective for dates of service on and after September 1, 2019, the following specialty pharmacy codes from new or current clinical criteria or guideline will be included in our pre-service clinical review process.

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

The following clinical criteria or guideline will be effective September 1, 2019.

Clinical Criteria/Guideline	HCPCS or CPT Code(s)	NDC Code(s)	Drug
CG-DRUG-98	C9042, J9999	42367-0520-25	Belrapzo™
ING-CC-0088	C9399, J9999	72187-0401-01	Elzonris™
ING-CC-0087	C9399, J3590	72171-0501-01 72171-0505-01	Gamifant®
ING-CC-0041	C9399, J3590	25682-0022-01	Ultomiris™
ING-CC-0086	J3490	50458-0028-00 50458-0028-02 50458-0028-03	Spravato™