Starting for DOS on 04/01/2021 and thereafter, the following medications will be added to BCBS NY Medicaid Step Therapy.
Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review.
To see the full clinical criteria/medical policy for Ocrevus, please click here.
To see the full clinical criteria/medical policy for Eptinezumab, please click here.
This policy is for site of care medical necessity review and it only applies to administration performed in an outpatient hospital setting.
This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Empire is the secondary payer.
The medical necessity Review will be performed by AIM Specialty Health® (AIM).
AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Empire’s Medical Policy and Clinical UM Guideline page and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.
The following codes apply to this policy:
To Submit a request for review:
Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:
This review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at empireblue.com/provider.
**Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use “site of care.”**
PA requirements will be added to the following codes:
Federal and state law, as well as state contract language, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.
KR2 Medical Billing 