Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

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