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

Please note, this communication applies to Healthy Blue + Medicare^℠ (HMOD-SNP) offered by Blue Cross and Blue Shield of North Carolina.

Effective June 1, 2023, the following Part B medications from the current Clinical Criteria 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 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-1017 (PDF)	Avastin Mvasi	Alymsys Vegzelma Zirabev

For more information, visit Healthy Blue + Medicare.

Blue Cross and Blue Shield of North Carolina Senior Health, DBA Blue Cross and Blue Shield of North Carolina, is an HMO D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal

NCBCBS-CR-022279-23-CPN22010 April 2023