Material Adverse Change (MAC)

 

Specialty pharmacy updates for Empire BlueCross BlueShield 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.

 

Inclusion of the National Drug Code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified code.

 

Step therapy updates

Effective for dates of service on and after January 1, 2023, 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. 

 

Please note that infliximab agents are subject to step therapy today, and this is to notify of the changes in the preferred and nonpreferred products. Inflectra will become non-preferred and Avsola will become preferred as of January 1, 2023.

 

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-0062

Preferred

Avsola

Q5121

ING-CC-0062

Preferred

Infliximab Unbranded

J1745

ING-CC-0062

Preferred

Remicade

J1745

ING-CC-0062

Non-preferred

Inflectra

Q5103

ING-CC-0062

Non-preferred

Renflexis

Q5104


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

 

NYBCBS-CM-007038-22-CPN6800



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October 2022 Newsletter