Clinical criteria updates for specialty pharmacy

On December 1, 2018, Empire introduced the new clinical criteria page for injectable, infused or implanted drugs.

 

Effective for dates of service on and after August 1, 2019, the following new oncology clinical criteria will be included in our clinical criteria review process.  The oncology drugs that require prior authorization will continue to require prior authorization notification with AIM. 

 

Existing precertification requirements have not changed for the specific Clinical Criteria below.  While there are no material changes, the document number and online location has changed.  Go online to access the clinical criteria information.  The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical Guideline/Medical Policy.

 

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

 

Clinical Guideline	Clinical Criteria Document Number	Clinical Criteria Name	Drug	HCPCS Code
CG-DRUG-76	ING-CC-0089	Mozobil (plerixafor)	Mozobil	J2562