Specialty pharmacy drug list update

Effective for dates of service on Jan. 1, 2022, we’re adding the following specialty medications to our specialty pharmacy requirements drug list for UnitedHealthcare commercial plans.

HCPCS code

Medication

Therapeutic class

Specialty pharmacy

J3490

J3590

C9399

Nexviazyme™

Enzyme replacement therapy

Orsini Pharmaceutical Services

J3490

J3590

C9399

Saphnelo™

Immune modulator

US Bioservices

The planned Jan. 1 addition of Ryplazim® is postponed and the new date for including in the drug list is to be determined.

Specialty pharmacy requirement

Outpatient hospitals are required to obtain the medications listed above from the indicated specialty pharmacies for administration of these medications, unless otherwise authorized by us. In the event the specialty medication is obtained through the specialty pharmacy, the specialty pharmacy will bill us directly for these medications under the member’s medical benefit.

Questions? Please contact your Network Management or Provider Relations teams.

PCA-21-03195