Specialty pharmacy updates

Prior authorization updates

Effective for dates of service on and after June 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.

 

Visit our website to access the clinical criteria information.  

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0185	J3490, C9399	Oxlumo
**ING-CC-0184	J3490, J3590, J9999	Danyelza

*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).

 

Prior authorization update – change in effective date

Please note the change in date for the implementation of prior authorization for the injectable iron deficiency anemia products listed below. The effective date previously communicated was March 1, 2021.

 

Effective for dates of service on and after May 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.

 

Visit our website to access the clinical criteria information.  

 

Clinical Criteria	HCPCS or CPT Code	Drug
*ING-CC-0182	J1756	Venofer
*ING-CC-0182	J2916	Ferrlecit
*ING-CC-0182	J1750	Infed
*ING-CC-0182	J1439	Injectafer
*ING-CC-0182	Q0138	Feraheme
*ING-CC-0182	J1437	Monoferric

*Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team.

 

Step therapy update – change in effective date

Please note the change in date for the implementation of step therapy for the injectable iron deficiency anemia products listed below. The effective date previously communicated was March 1, 2021.

 

Effective for dates of service on and after May 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. 

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.

 

Visit our website to access the clinical criteria information.  

 

Clinical Criteria	Status	Drug	HCPCS Codes
*ING-CC-0182	Preferred	Venofer	J1756
*ING-CC-0182	Preferred	Ferrlecit	J2916
*ING-CC-0182	Preferred	Infed	J1750
*ING-CC-0182	Non-preferred	Injectafer	J1439
*ING-CC-0182	Non-preferred	Feraheme	Q0138
*ING-CC-0182	Non-preferred	Monoferric	J1437

*Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by the medical specialty drug review team.

 

Prior authorization update - codes removed from prior authorization requirement

In a recent notification, we shared that effective April 1, 2021, the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization review process at this time.

 

Clinical Criteria	HCPCS or CPT Code	Drug
ING-CC-0095	J9041	Velcade (Bortezomib)
ING-CC-0095	J9044	Bortezomib
ING-CC-0093	J9171	Docetaxel

 

Medical specialty pharmacy update – removal of prior authorization requirement for certain drugs used to treat ocular conditions   

In an effort to help simplify care and support our providers, effective May 1, 2021, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions.

 

Drug	Code(s)	Code description
Avastin	C9257, J9035	Intravitreal bevacizumab
Mvasi	Q5107	Bevacizumab-awwb
Zirabev	Q5118	Bevacizumab-bvzr

 

1007-0321-PN-NE