Updates for specialty pharmacy are available

Prior authorization updates

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of NDC code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the Clinical Criteria information please click here.  

 

Empire BlueCross BlueShield’s (“Empire”) prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team.  Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0164	J3490 J9999 C9399	Jelmyto
ING-CC-0165	J3490 J3590 J9999 C9399	Trodelvy
ING-CC-0061	J1950 J3490	Fensolvi

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

Oncology use is managed by AIM.

 

Site of care updates

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization site of care review process.

 

To access the site of care drug list, please click here.  

 

Empire’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are in italics.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0153	J0791	Adakveo (crizanlizumab)
ING-CC-0139	J3111	Evenity (romosozumab)
ING-CC-0154	J0223	Givlaari (givosiran)
ING-CC-0156	J0896	Reblozyl (luspatercept)
ING-CC-0003	J1558	Xembify (immune globulin)
*ING-CC-0002	Q5120	Ziextenzo (pegfilgrastim-bmez)

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

Oncology use is managed by AIM.

 

REMINDER: Process for Medical Non-Oncology Specialty drug reviews:

 

Action	Contact
Submit a new prior authorization request for a medical specialty drug review    Submit a reauthorization request for a medical specialty drug review previously performed by AIM	Call IngenioRx at 1-833-293-0659 or Fax IngenioRx at 1-888-223-0550
Inquire about an existing request (initially submitted to AIM or Empire), peer-to-peer review, or reconsideration	Call IngenioRx

 

Please note:

• AIM continues to be responsible for performing medical oncology drug reviews for existing commercial medical benefit for our employer group business.
• Clinical criteria for medical non-oncology specialty drugs continue to reside on the Clinical Criteria webpage.
• Post service clinical coverage reviews and grievance and appeals process and teams have not changed.

 

637-0920-PN-NY