Prior authorization updates for specialty pharmacy are available

Quantity limit updates

Effective for dates of service on and after November 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization quantity limit review process.

 

To access the Clinical Criteria information please click here.  

 

Empire BlueCross BlueShield’s (“Empire”) prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0044	J1428	Exondys 51
ING-CC-0058	J2354	Bynfezia
ING-CC-0072	J0179	Beovu
ING-CC-0075	Q5119	Ruxience
ING-CC-0152	J1429	Vyondys 53
ING-CC-0153	C9053	Adakveo

* Non-oncology use is managed by Empire's medical specialty drug review team. Oncology use is managed by AIM.

 

Clinical criteria updates

Effective for dates of service on and after November 1, 2020, the following clinical criteria document was revised and might result in services that were previously covered but may now be found to be not medically necessary in our prior authorization review process.

 

To access the Clinical Criteria information please click here.  

 

Empire’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.

• ING-CC-0003 Immunoglobulins

Updated medical necessity criteria for myasthenia gravis to include specific drug failures and chronic inflammatory demyelinating polyneuropathy to include requirements regarding disease duration, specific electrodiagnostic criterion, and objective measures for continuation.

 

Correction to prior authorization update on clinical criteria ING-CC-0157 published May 1st:

The HCPCS codes available for Padcev at the time of the May 1^st article were C9399, J3490 and J9999; and not J9309 as erroneously stated that month’s newsletter.

 

581-0820-PN-NY