New specialty pharmacy medical step therapy requirements (Herceptin)

Effective for dates of service on and after January 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.

 

The Clinical Criteria below will be updated to include the requirement of a preferred agent effective January 1, 2021.

 

Clinical Criteria	Preferred drug	Nonpreferred drug
ING-CC-0166	Herzuma (Q5113), Kanjinti (Q5117), Ogivri (Q5114), Ontruzant (Q5112), Trazimera (Q5116)	Herceptin (J9355)

 

Clinical Criteria is publicly available on our provider website at www.empireblue.com/nymedicaiddoc.

 

What if I need assistance?

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

 

NYE-NU-0257-20 September 2020