Maine
Provider Communications
Specialty pharmacy medical step therapy drug list expanded
Agents for Hereditary Angioedema ING-CC-0034
Effective for dates of service on and after August 1, 2019, the following specialty pharmacy codes from new or current clinical criteria will be included in our existing specialty pharmacy medical step therapy review process. Haegarda® and Takhzyro™ will be the preferred prophylactic agents over Cinryze®.
Please note, inclusion of NDC code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the clinical criteria information please click here.
Clinical Criteria |
Status |
Drug |
HCPCS or CPT Code |
NDC Code |
ING-CC-0034 |
Preferred Agent |
Haegarda® |
J0599 |
63833-0828-02 63833-0829-02 |
ING-CC-0034 |
Preferred Agent |
Takhzyro™ |
J3490, J3590, C9399 |
47783-0644-01 |
ING-CC-0034 |
Non-Preferred Agent |
Cinryze® |
J0598 |
42227-0081-05 |
Featured In:
May 2019 Anthem Maine Provider Newsletter