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 upon 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


Herzuma (Q5113), Kanjinti (Q5117), Ogivri (Q5114), Ontruzant (Q5112), Trazimera (Q5116)

Herceptin (J9355)


Clinical Criteria is publicly available on our provider website at 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


NYE-NU-0257-20 September 2020


Featured In:
November 2020 Empire Provider News