Specialty pharmacy updates are available - November 2021

Material Adverse Change (MAC) notification

Specialty pharmacy updates for Empire BlueCross BlueShield (“Empire”) are listed below.

 

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

 

Please note that 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 February 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	HCPCS or CPT Code(s)	Drug
ING-CC-0096**	J3590	Rylaze
ING-CC-0167**	Q5119	Ruxience
ING-CC-0167**	Q5115	Truxima
ING-CC-0202	J3490 J3590	Saphnelo
ING-CC-0203	J3490 J3590	Ryplazim

* Non-oncology use is managed by the medical specialty drug review team.

** 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 February 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. 

 

Clinical Criteria	Status	HCPCS or CPT Code(s)	Drug
ING-CC-0075*	Preferred	J9312	Rituxan
		Q5123	Riabni
	Non-preferred	Q5119	Ruxience
		Q5115	Truxima
ING-CC-0167**	Preferred	J9312	Rituxan
		Q5123	Riabni
	Non-preferred	Q5119	Ruxience
		Q5115	Truxima

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

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

 

Quantity limit updates

 

Effective for dates of service on and after February 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	HCPCS or CPT Code(s)	Drug
ING-CC-0081	J0584	Crysvita
ING-CC-0202	J3490 J3590	Saphnelo

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

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