Specialty pharmacy medical step therapy requirements
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Defines new specialty pharmacy codes subject to Empire BlueCross's medical step therapy review for prior authorizations and renewals, affecting providers requesting coverage for listed specialty drugs.
Specific specialty pharmacy codes and associated Clinical Criteria (ING-CC-0002) for listed drugs were added to the existing specialty pharmacy medical step therapy review process effective May 8, 2023.
Coverage Criteria
Step therapy + medical necessity
Covered when prior authorization and step therapy criteria in the referenced Clinical Criteria are met
Providers must consult ING-CC-0002 for specific step sequences and exceptions
No product-specific exclusions are listed in this document. Providers should consult the referenced Clinical Criteria (ING-CC-0002) for any product-specific exclusions that may apply to the specialty pharmacy codes listed under this policy.
This policy does not enumerate discrete not medically necessary (NMN) conditions. Requests will be evaluated against the step therapy requirements and medical necessity criteria in Clinical Criteria ING-CC-0002; failure to meet those step therapy or medical necessity requirements may render a request not medically necessary and subject to denial.
Coding / Billing Codes
Provider Actions & Prior Authorization
Application of step therapy per ING-CC-0002
Step therapy review per Clinical Criteria ING-CC-0002 will be applied when prior authorization is initiated or renewed for the drugs listed under ING-CC-0002.
Documentation and clinical criteria reference
Providers must submit prior authorization requests or renewals for the listed HCPCS codes; the Clinical Criteria (ING-CC-0002) published on the payer's provider website will be used to evaluate step therapy and medical necessity.
Step therapy review may trigger denial if requirements unmet
Prior authorization requests or renewals for the listed specialty pharmacy drugs are subject to step therapy review; failure to meet the step therapy requirements in ING-CC-0002 may result in denial.
Background
Minimal background is provided in this document. It notifies providers that specialty pharmacy codes were added to the existing medical step therapy review process effective May 8, 2023, and that the list of Clinical Criteria, including ING-CC-0002, is published on the payer's provider website for detailed clinical guidance.
Definitions & References
Step Therapy Application
| HCPCS | Drug | Clinical Criteria | Step therapy review applies |
|---|---|---|---|
| Q5101 | Zarxio | ING-CC-0002 (Preferred) | Covered with step therapy per ING-CC-0002 at prior authorization initiation or renewal |
| J1447 | Granix | ING-CC-0002 (Non‑Preferred) | Step therapy review per ING-CC-0002 will be applied at prior authorization initiation or renewal |
| J1442 | Neupogen | ING-CC-0002 (Non‑Preferred) | Step therapy review per ING-CC-0002 will be applied at prior authorization initiation or renewal |
| Q5110 | Nivestym | ING-CC-0002 (Non‑Preferred) | Step therapy review per ING-CC-0002 will be applied at prior authorization initiation or renewal |
| Q5125 | Releuko | ING-CC-0002 (Non‑Preferred) | Step therapy review per ING-CC-0002 will be applied at prior authorization initiation or renewal |
Biosimilar Status
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