October Prior Approval Quarterly Update

Date Issued: 10/29/2018

Effective 10/01/2018, prior approval will be required for the following services:

Q5108 - Injection, pegfilgrastim-jmdb (Fulphila), biosimilar, 0.5 mg
Q5510 - Injection, filgrastim-aafi (Nivestym), biosimilar, 1 microgram
C9033 - Injection, fosnetupitant 235 mg and palonosetron 0.25 mg
C9034 - Injection, dexamethasone 9%, intraocular, 1 mcg

These codes were released by the Centers for Medicare & Medicaid Services (CMS) on 08/10/2018 and 08/31/2018, respectively, with an effective date of 10/1/2018.

Detailed medical policies are available at emblemhealth.com/Providers/Medical-Policies/Medical-Policies.