Effective for dates of service on and after September 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy level of care review process.

 

Level of care pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health (AIM), a separate company.

 

View the Clinical Site of Care (Level of Care) drug list and Clinical Site of Care (Level of Care) pre-service clinical review FAQs for more information.

Clinical UM Guideline or Medical Policy

Drug Name

Drug Code

CG-DRUG-05

Mircera®

J0888

CG-DRUG-09

CuvitruTM

J1555

CG-DRUG-16

Zarxio®

Q5101

CG-DRUG-44

Krystexxa®

J2507

CG-DRUG-61

Supprelin LA®

J9226

CG-DRUG-69

Stelara®

J3358

CG-DRUG-78

Fibryga®

J7178

CG-DRUG-78

Rebinyn®

J7195

DRUG.00027

Prialt®

J2278

DRUG.00081

Exondys 51TM

J1428

DRUG.00093

KanumaTM

J2840

DRUG.00095

OcrevusTM

J2350



Featured In:
June 2018 New Hampshire newsletter