Products & Programs Federal Employee Program (FEP)CommercialJune 30, 2019

Empire Federal Employee Health Benefit Program® (FEP) PPO Members will now require prior approval for specific Specialty Drugs and Site of Care

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Effective July 1, 2019, Empire Federal Employee PPO members, (ID numbers beginning with an, ‘R’), aged 18 and older, and not Medicare Primary, will now need to have Prior Approval for the following medications:

 

List of medications by name and code

Code

Procedure Description

CODE

Procedure Description

J0129

Abatacept injection (Orencia)

J1575

Injection, immune globulin/hyaluronidase  (HyQvia)

J0490

Belimumab injection (Benlysta)

J1599

Injection, immune globulin (Panzyga)

J1459

Injection, immune globulin (Privigen)

J1602

Golimumab IV (Simponi Aria)

J1555

Injection, immune globulin (Cuvitru)

J1745

Infliximab not biosimilar (Remicade)

J1556

Injection, immune globulin (Bivigam)

J2323

Natalizumab injection (Tysabri)

J1557

Injection, immune globulin (Gammaplex)

J3380

Vedolizumab Injection (Entyvio)

J1559

Injection, immune globulin (Hizentra)

Q5103

Infliximab dyyb biosimilar (Inflectra)

J1561

Injection, immune globulin (Gamunex-c/Gammaked)

Q5104

Infliximab abda biosimilar (Renflexis)

J1566

Injection, immune globulin (Carimune)

Q5109

infliximab-qbtx, biosimilar (Ixifi)

J1568

Injection, immune globulin (Octagam)

J1569

Injection, immune globulin, (Gammagard liquid)

J1572

Injection, immune globulin , (Flebogamma)

 

 

 

In addition to acquiring Prior Approval for the medication, the Outpatient Hospital Site of Care must also be approved.  The Prior Approval process will identify members who meet the appropriate Empire site of care criteria and who can safely receive their medication in a location other than an outpatient hospital, including the home.

Effective January 1, 2020 failure to receive Prior Approval for these medications may result in non-coverage of the medication and facility services. 

 

To acquire Prior Approval please contact the Empire Federal Employee Program Utilization Management Department at 1-800-860-2156.

PUBLICATIONS: July 2019 Empire Provider News