CommercialOctober 1, 2019
Anthem specialty pharmacy medical step therapy drug list- clarification
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 |
ATTACHMENTS: 2019-02 Biosimilars article_v1.4.pdf (pdf - 0.16mb)
PUBLICATIONS: October 2019 Anthem Provider News - Kentucky
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