New specialty pharmacy medical step therapy requirements

Effective for dates of service on and after March 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation or renewal, in addition to the current medical necessity review of all drugs noted below.

 

Below are the Clinical Criteria that have been updated to include the requirement of a preferred agent effective March 1, 2021.

 

The Clinical Criteria are made publicly available on the Empire BlueCross BlueShield HealthPlus provider website. Visit https://bit.ly/3quo9A5 to search for specific Clinical Criteria.

 

Clinical Criteria	Status	Drug name	HCPCS code
ING-CC-0002	Preferred	Neulasta	J2505
ING-CC-0002	Preferred	Udenyca	Q5111
ING-CC-0002	Non-preferred	Fulphila	Q5108
ING-CC-0002	Non-preferred	Ziextenzo	Q5120
ING-CC-0002	Non-preferred	Nyvepria	J3590

 

NYEPEC-2573-20 December 2020