New specialty pharmacy medical step therapy requirements

Effective for dates of service on and after September 15, 2022, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy 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.

 

Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.

 

Clinical Criteria	Status	Drug(s)	HCPCS codes
ING-CC-0075 ING-CC-0167	Preferred	Riabni	Q5123
ING-CC-0075 ING-CC-0167	Non-Preferred	Rituxan	J9312
ING-CC-0075 ING-CC-0167	Non-preferred	Ruxience	Q5119
ING-CC-0075 ING-CC-0167	Non-preferred	Truxima	Q5115

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Experience associate or call Provider Services at

855-661-2028.

 

KYBCBS-CD-004808-22 (AKYPEC-3130-22)