CommercialMay 1, 2019
Anthem specialty pharmacy medical step therapy drug list clarification about non-oncology colony stimulating factor agents
Colony Stimulating Factor Agents ING-CC-0002
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™®.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Additional information regarding biosimilar drugs can be found by viewing the attached reference document titled “Biosimilar Drugs – What are they?”
To access the clinical criteria information, visit the Anthem Clinical Criteria webpage.
Clinical Criteria |
Status |
Drug |
HCPCS or CPT Code |
NDC Code |
ING-CC-0002 |
Preferred Agent |
Zarxio® |
Q5101 |
61314-0304-01 61314-0304-10 61314-0312-01 61314-0312-10 61314-0318-01 61314-0318-10 61314-0326-01 61314-0326-10 |
ING-CC-0002 |
Non-Preferred Agent |
Neupogen® |
J1442 |
55513-0530-01 55513-0530-10 55513-0546-01 55513-0546-10 55513-0924-01 55513-0924-10 55513-0924-91 55513-0209-01 55513-0209-10 55513-0209-91 |
ING-CC-0002 |
Non-Preferred Agent |
Granix® |
J1447 |
63459-0910-11 63459-0910-12 63459-0910-15 63459-0910-17 63459-0910-36 63459-0912-11 63459-0912-12 63459-0912-15 63459-0912-17 63459-0912-36 |
ING-CC-0002 |
Non-Preferred Agent |
Nivestym™ |
Q5110 |
00069-0291-10 00069-0291-01 00069-0292-01 00069-0292-10 |
ATTACHMENTS: Biosimilars – What are they 5.1.2019.pdf (pdf - 0.26mb)
PUBLICATIONS: Anthem May 2019 Provider News - Georgia
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