MedicaidJanuary 8, 2025
New specialty pharmacy medical step therapy requirements
Effective on March 1, 2025, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal, in addition to the current medical necessity review of all drugs noted below.
The list of Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.
Clinical Criteria | Status | Drug(s) | HCPCS codes |
CC‑0078 | Non‑Preferred | Orencia | J0129 |
CC‑0078 | Preferred | Avsola | Q5121 |
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
CABC-CD-072373-24-CPN72295
PUBLICATIONS: February 2025 Provider Newsletter
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