Empire expands specialty pharmacy medical step therapy drug list

The following clinical criteria will be effective May 1, 2019.

 

Colony Stimulating Factor Agents ING-CC-0002

Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™®.

 

Empire’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.

 

Additional information regarding biosimilar drugs can be found by viewing the attached reference document, “Biosimilar Drugs – What are they?”

 

To access the clinical criteria information please click here.

 

Clinical Criteria	Status	Drug	HCPCS or CPT Code	NDC Code
ING-CC-0002	Preferred Agent	Zarxio®	Q5101	61314-0304-01 61314-0304-10 61314-0312-01 61314-0312-10 61314-0318-01 61314-0318-10 61314-0326-01 61314-0326-10
ING-CC-0002	Non-Preferred Agent	Neupogen®	J1442	55513-0530-01 55513-0530-10 55513-0546-01 55513-0546-10 55513-0924-01 55513-0924-10 55513-0924-91 55513-0209-01 55513-0209-10 55513-0209-91
ING-CC-0002	Non-Preferred Agent	Granix®	J1447	63459-0910-11 63459-0910-12 63459-0910-15 63459-0910-17 63459-0910-36 63459-0912-11 63459-0912-12 63459-0912-15 63459-0912-17 63459-0912-36
ING-CC-0002	Non-Preferred Agent	Nivestym™	Q5110	00069-0291-10 00069-0291-01 00069-0292-01 00069-0292-10