New Specialty Pharmacy Medical Step Therapy Requirements (Healthy Blue + Medicare HMO-DSNP)

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina.

Effective December 1, 2022, the following Part B medications from the current Clinical Utilization Management (UM) Guidelines will be 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.

Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

Clinical UM Guidelines

• ING-CC-0002

Preferred Drug

• Zarxio

Nonpreferred Drugs

• Granix
• Neupogen
• Nivestym
• Releuko