Specialty pharmacy site of care reviews for NYSHIP Empire Plan members

Effective July 1, 2023, specialty pharmacy site of care reviews are required for New York State Health Insurance Program (NYSHIP) Empire Plan members. NYSHIP Empire Plan members are billed under the dedicated prefix YLS. Anthem administers the Empire Plan Hospital Program. Pre-determination clinical review of non-oncology use of specialty pharmacy drugs is managed by the clinical team dedicated to NYSHIP Empire Plan members:

• Important note: Currently your NYSHIP Empire Plan patients may receive infusions of these medications without a predetermination of benefits. As of July 1, 2023, it is strongly recommended you request a predetermination of benefits for your patients’ continued infusions of these medications. Access our Clinical Criteria to view the complete information for these predetermination requests.

Effective for dates of service on and after July 1, 2023, the specialty pharmacy codes from current or new clinical criteria documents are included in our site of care review process. Drugs excluded from our site of care review process include oncology drugs, drugs used to treat hemophilia, and injectables.

• Access the NYSHIP Empire Plan Site of Care Drug List to view the complete information for these site of care updates and to view the complete list of drugs subject to site of care review.

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