Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina.
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:
- ING-CC-0005
PREFERRED DRUG(S):
- Euflexxa (J7323)
- Supartz FX (J7321)
- Durolane (J7318)
- Gelsyn-3 (J7328)
NONPREFERRED DRUG(S):
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)
For more provider D-SNP resources, visit our Healthy Blue + Medicare page.
BNCCARE-0190-21 August 2021 519447MUPENMUB
