Specialty pharmacy updates

Material Adverse Change (MAC)

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire BlueCross BlueShield’s (“Empire”) medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_® (AIM), a separate company.

 

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.

 

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.

 

Prior authorization updates

Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

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

Clinical Criteria	Drug	HCPCS or CPT Code(s)
ING-CC-0072	Alymsys (bevacizumab-maly)	C9399, J3490, J3590
ING-CC-0107*	Alymsys (bevacizumab-maly)	C9399, J3490, J3590, J9999
ING-CC-0216*	Opdualag (nivolumab and relatlimab-rmbw)	C9399, J3490, J3590, J9999
ING-CC-0118*	Pluvicto (lutetium lu 177 vipivotide tetraxetan)	A9699
ING-CC-0002*	Releuko (filgrastim-ayow)	C9096

* Oncology use is managed by AIM.

 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

Step therapy updates

Effective for dates of service on and after November 1, 2022, 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. 

 

Access our Clinical Criteria to view the complete information for these step therapy updates.

 

Clinical Criteria	Status	Drug	HCPCS or CPT Code(s)
ING-CC-0107*	Non-preferred	Alymsys	C9399, J3490, J3590, J9999
ING-CC-0002*	Non-preferred	Releuko	C9096

*Oncology use is managed by AIM.

 

Courtesy Notice

Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.

 

Quantity limit updates

Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

Access our Clinical Criteria to view the complete information for these quantity limit updates.

 

Clinical Criteria	Drug	HCPCS or CPT Code(s)
ING-CC-0072	Alymsys (bevacizumab-maly)	C9399, J3490, J3590

 

 

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

NYBCBS-CM-003589-22