Prior authorization updates for specialty pharmacy - effective March 1, 2021

Prior authorization updates

Effective for dates of service on and after March 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

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

 

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-0179	J9999	Blenrep
ING-CC-0180	J3490, J3590, J9999	Monjuvi
ING-CC-0182	J1756	Venofer
ING-CC-0182	J2916	Ferrlecit
ING-CC-0182	J1750	Infed
ING-CC-0182	J1439	Injectafer
ING-CC-0182	Q0138	Feraheme
ING-CC-0182	J1437	Monoferric

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

 

Step therapy updates

Effective for dates of service on and after March 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

 

To access the Clinical Criteria information related to Step Therapy, 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.

 

Clinical Criteria	Status	Drug(s)	HCPCS Codes
ING-CC-0182	Preferred	Venofer	J1756
ING-CC-0182	Preferred	Ferrlecit	J2916
ING-CC-0182	Preferred	Infed	J1750
ING-CC-0182	Non-preferred	Injectafer	J1439
ING-CC-0182	Non-preferred	Feraheme	Q0138
ING-CC-0182	Non-preferred	Monoferric	J1437
ING-CC-0174	Non-preferred	Kesimpta	J3490 (NOC)
ING-CC-0174	Non-preferred	Kesimpta	J3590 (NOC)
ING-CC-0174	Non-preferred	Kesimpta	C9399 (NOC)

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

 

Effective on or after January 1, 2021, documentation may be required to support step therapy reviews.

 

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