Effective for dates of service on and after September 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy level of care review process.

 

Empire’s level of care prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.

 

View the Clinical Site of Care (Level of Care) drug list and Clinical Site of Care (Level of Care) priro authorization clinical review FAQs for more information.

 

Medical Policy or

Clinical Guideline

Drug

Code

CG-DRUG-09

CuvitruTM

J1555

DRUG.00081

Exondys 51TM

J1428

CG-DRUG-78

Fibryga®

J7178

DRUG.00093

KanumaTM

J2840

CG-DRUG-44

Krystexxa®

J2507

CG-DRUG-05

Mircera®

J0888

DRUG.00095

OcrevusTM

J2350

DRUG.00027

Prialt®

J2278

CG-DRUG-78

Rebinyn®

J7195

CG-DRUG-69

Stelara®

J3358

CG-DRUG-61

Supprelin LA®

J9226

CG-DRUG-16

Zarxio®

Q5101

 



Featured In:
June 2018 Empire Provider Newsletter