Effective November 1, 2021, the Clinical Criteria ING-CC-0005 will include a trial and inadequate response or intolerance to two preferred hyaluronan agents in the Part B medical step therapy precertification review. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as-is current procedure). Step therapy will not apply for members who are actively receiving non-preferred medications listed below.

 

Clinical Criteria are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

 

Clinical Criteria

Preferred drug(s)

Nonpreferred drug(s)

ING-CC-0005

Euflexxa (J7323)

Supartz FX (J7321)

Durolane (J7318)

Gelsyn-3 (J7328)

Including but not limited to:

·         Gel-One (J7326)

·         GenVisc 850 (J7320)

·         Hymovis (J7322)

·         Monovisc (J7327)

·         Orthovisc (J7324)

·         Synvisc/Synvisc One (J7325)

·         TriVisc (J7329)

·         Hyalgan/Visco-3 (J7321)

·         Triluron (J7332)

 

EBSCARE-0649-21 August 2021

519447MUPENMUB

 



Featured In:
October 2021 Newsletter