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Appendix Z

List of Outpatient Hospital Specialty Drugs

For the Outpatient Hospital Specialty Drugs which are carved out from Enhanced Ambulatory Patient Group (EAPG) payment and their corresponding codes for use in billing, please refer to the Outpatient Hospital Specialty Drugs List.

This is a resource list of the medication names of the current outpatient hospital specialty drugs which are carved out from Enhanced Ambulatory Patient Group (EAPG) payment with an approved, member-specific prior authorization (PA).

For the corresponding Healthcare Common Procedure Coding System (HCPCS) codes and National Drug Code (NDC) numbers for use in billing, please refer to Appendix X: The HCPCS/NDC Crosswalk for billing Physician Administered Drugs (PADs).

Appendix Z Revision Log

Revision DateSection/ActionMade By
9/26/2019Initial Posting of Manual             DXC
7/1/2020Update of Outpatient Hospital Specialty Drugs List        DXC
7/1/2021Update of Outpatient Hospital Specialty Drugs ListDXC
7/29/2022Update of Outpatient Hospital Specialty Drugs ListGainwell Technologies
10/13/2022Update of Outpatient Hospital Specialty Drugs ListGainwell Technologies
12/8/2022Update of Outpatient Hospital Specialty Drugs ListGainwell Technologies
4/4/2023Added description of specialty drug listHCPF
5/17/2023Update of Outpatient Hospital Specialty Drugs ListGainwell Technologies
9/13/2023Update of Outpatient Hospital Specialty Drugs ListGainwell Technologies
11/30/2023Updated Outpatient Hospital Specialty Drugs ListGainwell Technologies
12/05/2023Updated Outpatient Hospital Specialty Drugs ListGainwell Technologies