Effective for dates of service on and after January 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply on precertification initiation or renewal in addition to the current medical necessity review of all drugs noted below.


The clinical criteria below will be updated to include the requirement of a preferred agent effective

January 1, 2021.


Clinical criteria

Preferred drug

Nonpreferred drug


Mvasi (Q5107), Zirabev (Q5118)

Avastin (J9035)


The Clinical Criteria is publicly available on http://www.empireblue.com/nymedicaiddoc.


What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services toll free at 1-800-450-8753.


NYE-NU-0258-20 September 2020

Featured In:
November 2020 Empire Provider News