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