Nevada specialty pharmacy updates (MAC)

Material adverse change (MAC)

 

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our prior authorization (PA) review process.

 

Please note that the inclusion of a National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

Clinical Criteria is available 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), a separate company.

 

Clinical Criteria	Drug	HCPCS or CPT Code
ING-CC-0096*	Rylaze(asparaginase erwinia chrysanthemi (recombinant)-rywn)	J3590
ING-CC-0167*	Ruxience	Q5119
ING-CC-0167*	Truxima	Q5115
ING-CC-0202	Saphnelo (anifrolumab-fnia)	J3490, J3590
ING-CC-0203	Ryplazim (plasminogen, human-tvmh)	J3490, J3590

      *Oncology use is managed by AIM

 

Step therapy updates

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process. 

    

Clinical Criteria	Status	Drug	HCPCS or CPT Code(s)
ING-CC-0075	Preferred	Rituxan	J9312
		Riabni	Q5123
	Non-preferred	Ruxience	Q5119
		Truxima	Q5115
ING-CC-0167*	Preferred (no PA or step therapy required)	Rituxan	J9312
		Riabni	Q5123
	Non-preferred	Ruxience	Q5119
		Truxima	Q5115

      *Oncology use is managed by AIM

 

Quantity limit updates

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our quantity limit review process.

 

Clinical Criteria	Drug	HCPCS or CPT Code
ING-CC-0081	Crysvita (burosumab-twza)	J0584
ING-CC-0202	Saphnelo (anifrolumab-fnia)	J3490, J3590

 

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