New specialty pharmacy medical step therapy requirements (MAC)

Medicaid

Material adverse change (MAC)

 

Effective for dates of service on and after October 1, 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 prior authorization initiation or renewal in addition to the current medical necessity review of all drugs noted below.

 

The list of 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-0107	Preferred	Mvasi	Q5107
ING-CC-0107	Non-preferred	Avastin	J9035
ING-CC-0107	Non-preferred	Zirabev	Q5118

 

NVBCBS-CD-005079-22-CPN4904