Specialty pharmacy updates - December 2021

Material Adverse Change (MAC)

 

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 March 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-0018	J3490 J3590 C9399	Nexviazyme (avalglucosidase alfa-ngpt)
*ING-CC-0034	J1744	Sajazir (icatibant)

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

 

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

 

Quantity limit updates

 

Effective for dates of service on and after March 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-0018	J3490 J3590 C9399	Nexviazyme (avalglucosidase alfa-ngpt)
*ING-CC-0034	J1744	Sajazir (icatibant)

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

 

1440-1221-PN-NY