New specialty pharmacy medical step therapy requirements

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation or renewal, in addition to the current medical necessity review of all drugs noted below.

 

The Clinical Criteria below will be updated to include the requirement of a preferred agent effective January 1, 2021.

 

Clinical Criteria	Preferred drug	Nonpreferred drug
ING-CC-0166	Herzuma (Q5113), Kanjinti (Q5117), Ogivri (Q5114), Ontruzant (Q5112), Trazimera (Q5116)	Herceptin (J9355)
ING-CC-0107	Mvasi (Q5107), Zirabev (Q5118)	Avastin (J9035)

Clinical Criteria is publicly available on our provider website at https://mediproviders.anthem.com/ca.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call one of our Medi-Cal Customer Care Centers at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County).