New specialty pharmacy medical step therapy requirements

Effective November 1, 2021, the Clinical Criteria ING-CC-0005 will include a trial and inadequate response or intolerance to two preferred hyaluronan agents in the Part B medical step therapy precertification review. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as-is current procedure). Step therapy will not apply for members who are actively receiving non-preferred medications listed below.

 

Clinical Criteria are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

Clinical Criteria	Preferred drug(s)	Nonpreferred drug(s)
ING-CC-0005	Euflexxa (J7323) Supartz FX (J7321) Durolane (J7318) Gelsyn-3 (J7328)	Including but not limited to: ·         Gel-One (J7326) ·         GenVisc 850 (J7320) ·         Hymovis (J7322) ·         Monovisc (J7327) ·         Orthovisc (J7324) ·         Synvisc/Synvisc One (J7325) ·         TriVisc (J7329) ·         Hyalgan/Visco-3 (J7321) ·         Triluron (J7332)

ACADPEC-0024-21/ACAD-NU-0170-21

519447-MUPENMUB