Effective for dates of service on and after January 1, 2019, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy clinically equivalent review process. Please note, inclusion of NDC code on your claim will shorten the claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

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

 

Medical Policy or

Clinical UM Guideline

 

Drug

 

HCPCS or CPT Code

 

NDC Code

 

CG-DRUG-09

Cuvitru™

 

 

 

 

 

 

 

J1555

00944-2850-06

00944-2850-07

00944-2850-08

00944-2850-04

00944-2850-02

00944-2850-01

00944-2850-03

00944-2850-05

CG-DRUG-09

Hizentra®

 

 

 

J1559

44206-0451-01

44206-0452-02

44206-0455-10

44206-0454-04

CG-DRUG-09

 

 

HyQvia®

 

 

 

 

J1575

00944-2513-02

00944-2512-02

00944-2514-02

00944-2510-02

00944-2511-02

 



Featured In:
October 2018 Empire Provider Newsletter