In the February and May editions of Provider News, we shared that the following clinical criteria will be effective May 1, 2019 for the non-oncology uses of these drugs. We will now also begin the medical step therapy review process for oncology uses of these drugs starting October 1, 2019.

 

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 Blue Cross and Blue Shield (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 reference document, “Biosimilar Drugs – What are they?” 

 

Click here to access the Clinical Criteria page on anthem.com.

 

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

 



Featured In:
October 2019 Anthem Provider News - Indiana