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: Durolane Three injection series: Euflexxa Gel-Syn Five injection series: Supartz	Single injection: Gel-One Monovisc Synvisc-one Two injection series: Hymovis Three injection series: Orthovisc Synojoynt Synvisc Triluron Trivisc Five injection series: Genvisc 850 Hyalgan Visco-3

For more information, please visit Healthy Blue + Medicare.

NCBCBS-CR-031135-23-CPN30365 August 2023