Updates for specialty pharmacy are available

Prior authorization updates

Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0027	J0897	Xgeva

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

** Oncology use is managed by AIM.

 

Quantity Limit Updates

Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

To access the Clinical Criteria information please click here.  

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0027	J0897	Xgeva

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

** Oncology use is managed by AIM.

 

1090-0421-PN-NY