Specialty pharmacy medical step therapy requirements (Part B medications)
Adds certain Part B specialty medications to Anthem's medical step therapy precertification review process effective July 1, 2022; applies to providers submitting precertification for affected medications; members actively receiving the listed medications are exempt from step therapy. Clinical UM Guidelines available on provider website.
Certain Part B specialty medications were added to the medical step therapy precertification review process effective July 1, 2022.
ING-CC-0107 designates Avastin and Mvasi as preferred and Zirabev as nonpreferred.
Coverage Criteria
Step therapy will not apply for members who are actively receiving the medications listed.
Provider Actions & Requirements
Step therapy applied at precertification
Step therapy review will be applied during precertification for the specified Part B specialty medications in addition to the standard medical necessity review. Providers must initiate precertification for these medications; failure to meet step therapy requirements at the time of precertification may result in denial.
- Effective Date: 2022-07-01
- Applies to listed Part B specialty medications from the Clinical UM Guidelines
- Step therapy review is not applied for members currently and actively receiving the listed medications
- Clinical UM Guidelines and specific criteria available on the provider website (Clinical Criteria page)
- Example guideline: ING-CC-0107 (Preferred: Avastin, Mvasi; Nonpreferred: Zirabev)
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