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Specialty Pharmacy Medical Step Therapy for Hyaluronan injections (Healthy Blue + Medicare (HMO D-SNP))
Please note, this communication applies to Healthy Blue + Medicare℠ (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina.
The following Part B medications from the current Clinical Criteria Guidelines are included in our medical step therapy precertification review process. 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 medications listed below.
There are no clinical changes to Clinical Criteria CC-005, Hyaluronan Injections. Based on feedback, the table listing the preferred and non-preferred products has been updated to present the information in a more useful manner. The updated table identifies preferred alternatives based on injection series.
Clinical Criteria Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.
| Clinical UM Guidelines | Preferred Drug(s) | Nonpreferred Drug(s) |
|---|---|---|
| CC-0005 | Single injection:
Three injection series:
Five injection series:
| Single injection:
Two injection series:
Three injection series:
Five injection series:
|
For more information, please visit Healthy Blue + Medicare.
NCBCBS-CR-031135-23-CPN30365 August 2023
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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