Products & Programs PharmacyCommercialDecember 30, 2022

Specialty pharmacy updates

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

The Medical Specialty Drug Review team for Empire BlueCross BlueShield manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. AIM Specialty Health®* (AIM), a separate company, manages review of specialty pharmacy drugs for oncology.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Including the national drug code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

Clinical Criteria update: Effective January 1, 2023, clinical criteria naming will be changed
from ING-CC-XXXX to CC-XXXX; however, the content within the documents will remain unchanged.

Prior authorization updates

Correction: In the August 2022 edition of Provider News, we published prior authorization updates for the drug Pluvicto (lutetium lu 177 vipivotide tetraxetan). Please be advised that the effective date for this update has been changed:

  • Previous effective date: November 1, 2022
  • Updated effective date: February 1, 2023

Access our Clinical Criteria to view the complete information for these prior authorization updates.

Clinical Criteria

Drug

HCPCS or CPT® code(s)

CC-0118*

Pluvicto (lutetium lu 177 vipivotide tetraxetan)

A9607

* Oncology use is managed by AIM.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield.

NYBCBS-CM-014743-22

PUBLICATIONS: January 2023 Newsletter