Anthem expands specialty pharmacy medical step therapy drug list

The following clinical criteria will be effective June 1, 2019.

 

Colony Stimulating Factor Agents ING-CC-0002

 

Effective for dates of service on and after June 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™®.

 

For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., pre-service clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Additional information regarding biosimilar drugs can be found in the reference document called: “Biosimilar Drugs: What are they?” 

 

Access the clinical criteria information.

 

Clinical Criteria	Status	Drug	HCPCS or CPT Code	NDC Code
ING-CC-0002	Preferred Agent	Zarxio®	Q5101	61314-0304-01 61314-0304-10 61314-0312-01 61314-0312-10 61314-0318-01 61314-0318-10 61314-0326-01 61314-0326-10
ING-CC-0002	Non-Preferred Agent	Neupogen®	J1442	55513-0530-01 55513-0530-10 55513-0546-01 55513-0546-10 55513-0924-01 55513-0924-10 55513-0924-91 55513-0209-01 55513-0209-10 55513-0209-91
ING-CC-0002	Non-Preferred Agent	Granix®	J1447	63459-0910-11 63459-0910-12 63459-0910-15 63459-0910-17 63459-0910-36 63459-0912-11 63459-0912-12 63459-0912-15 63459-0912-17 63459-0912-36
ING-CC-0002	Non-Preferred Agent	Nivestym™	Q5110	00069-0291-10 00069-0291-01 00069-0292-01 00069-0292-10