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
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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