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

 

NYBCBS-CD-002765-22 July 2022



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September 2022 Newsletter