New specialty pharmacy medical step therapy requirements

Effective for dates of service on and after May 1, 2019, the specialty pharmacy drugs and corresponding codes from current clinical criteria noted below will be included in our medical step therapy precertification review process. Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review (as is done currently).

 

The clinical criteria below have been updated to include the requirement of a preferred agent effective May 1, 2019.

 

Clinical criteria	Preferred drug	Nonpreferred drug
ING-CC-0001	Retacrit (Q5106)	Procrit (J0885)
ING-CC-0002	Zarxio (Q5101)	Neupogen (J1442), Granix (J1447) and Nivestym (Q5110)

 

The clinical criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific clinical criteria.

 

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-450-8753.