New specialty pharmacy medical step therapy requirements

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 precertification initiation or renewal in addition to the current medical necessity review of all drugs noted in the chart.

 

The Clinical Criteria are 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-0166	Preferred	Kanjinti	Q5117
ING-CC-0166	Non-preferred	Herceptin	J9355
ING-CC-0166	Non-preferred	Herzuma	Q5113
ING-CC-0166	Non-preferred	Ogivri	Q5114
ING-CC-0166	Non-preferred	Ontruzant	Q5112
ING-CC-0166	Non-preferred	Trazimera	Q5116

 

NYBCBS-CD-002765-22 July 2022