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Appendix Z

Hospital Specialty Drugs

For Hospital Specialty Drugs and their corresponding codes for use in billing, please refer to the Hospital Specialty Drugs List.

This is a resource list of the medication names and coverage standards of the current Hospital Specialty Drugs which are carved out from either the All-Patient Refined Diagnosis Related Group (APR-DRG) or the Enhanced Ambulatory Patient Group (EAPG) payment with an approved, member-specific prior authorization (PA).

PA forms and process documents can be found on the Physician-Administered Drug Provider Resources web page. 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
12/27/2023Updated page verbiage and format of Hospital Specialty Drug ListHCPF