Prior authorization updates for specialty pharmacy are available

Prior authorization updates

Effective for dates of service on and after May 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-0183	J3590	Sogroya
*ING-CC-0001	J0886	Injection, epoetin alfa (Procrit/Epogen)
*ING-CC-0019	J3489	Reclast, Zometa

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

 

Quantity Limit Updates

Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit 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’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	HCPCS or CPT Code(s)	Drug
*ING-CC-0019	J3489	Reclast, Zometa

 

979-0221-PN-NY