Products & Programs PharmacyMedicaidNovember 21, 2023

New specialty pharmacy medical step therapy requirements

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Effective for dates of service on and after January 1, 2024, 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.

Clinical Criteria CC-0041 will be adding step therapy, preferring Enspryng and Uplizna, for the indication of neuromyelitis optica spectrum disorder.

The searchable list of specific Clinical Criteria is publicly available on our provider website.

Clinical Criteria

Status

Drug(s)

HCPCS codes

CC-0041

Non-preferred

Soliris

J1300

CC-0041

Preferred

Enspryng

C9399, J3590

CC-0041

Preferred

Uplizna

J1823

We look forward to working together to achieve improved outcomes.

Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross Blue Shield Association.

CPN46328, NYBCBS-CD-046618-23, NYBCBS-CD-039000-23-CPN38894

PUBLICATIONS: December 2023 Provider Newsletter