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.

 

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

 

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 December 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

Drug

HCPCS or CPT® code(s)

ING-CC-0217

Amvuttra™ (vutrisiran)

J3490, J3590

ING-CC-0218

Xipere® (triamcinolone acetonide injectable suspension)

J3299

Note: Oncology use is managed by AIM.

 

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 December 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

Drug

HCPCS or CPT® code(s)

ING-CC-0217

Amvuttra (vutrisiran)

J3490, J3590

ING-CC-0218

Xipere (triamcinolone acetonide injectable suspension)

J3299

Note: Oncology use is managed by AIM.

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

 

NYBCBS-CM-004939-22



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September 2022 Newsletter