New Medical Step Therapy Requirements

Please note, this communication applies to Healthy Blue + Medicare^SM (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