New specialty pharmacy medical step therapy requirements

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

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

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

VAHK-CD-002767-22