New specialty pharmacy medical step therapy requirements

Medicare Advantage

Effective March 1, 2022, the following Part B medications from the current Clinical Utilization Management (UM) Guidelines will be included in our medical step therapy precertification review process. 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 medications listed below.

 

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

 

Clinical UM Guidelines	Preferred drug(s)	Nonpreferred drug(s)
ING-CC-0062	Inflectra Remicade, Infliximab (unbranded)	Avsola  Renflexis

 

 

ABSCRNU-0330-22

ABSCARE-1286-22