Effective November 1, 2021, the Clinical Criteria ING-CC-0005 will include a trial and inadequate response or intolerance to two preferred hyaluronan agents in the Part B medical step therapy precertification review. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as-is current procedure). Step therapy will not apply for members who are actively receiving non-preferred medications listed below.

 

Clinical Criteria are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

 

Clinical Criteria

Preferred drug(s)

Nonpreferred drug(s)

ING-CC-0005

Euflexxa (J7323)

Supartz FX (J7321)

Durolane (J7318)

Gelsyn-3 (J7328)

Including but not limited to:

Gel-One (J7326)

GenVisc 850 (J7320)

Hymovis (J7322)

Monovisc (J7327)

Orthovisc (J7324)

Synvisc/Synvisc One (J7325)

TriVisc (J7329)

Hyalgan/Visco-3 (J7321)

Triluron (J7332)

 

ABSCRNU-0266-21/ABSCARE-1058-21



Featured In:
October 2021 Anthem Provider News - Missouri