Policy Updates Prior AuthorizationMedicaidAugust 1, 2023

Fylnetra, Stimufend, and Rolvedon Medical Step Therapy Notice

New specialty pharmacy medical step therapy requirements

Beginning January 1, 2024, Amerigroup in Tennessee became Wellpoint. This article, published under the former brand, now applies to Wellpoint.

This is a correction to an article that was posted on August 1, 2023. The effective date was listed as September 1, 2023, in error. The correct effective date is October 1, 2023. 

Effective for dates of service on and after October 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal, in addition to the current medical necessity review of all drugs noted below.

Clinical Criteria CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro, and the biosimilar Udenyca. This update is to provide notification that the new biosimilars Fylnetra and Stimufend and the new long-acting colony stimulating factor Rolvedon will be added to existing step therapy as non-preferred agents.

The list of Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.

Clinical Criteria

Status

Drug(s)

HCPCS codes

CC-0002

Non-preferred

Fulphila

Q5108

CC-0002

Non-preferred

Fylnetra

J3590

CC-0002

Non-preferred

Nyvepria

Q5122

CC-0002

Non-preferred

Rolvedon

C9399, J3490, J3590

CC-0002

Non-preferred

Stimufend

C9399, J3490, J3590

CC-0002

Non-preferred

Ziextenzo

Q5120

CC-0002

Preferred

Neulasta

J2506

CC-0002

Preferred

Neulasta OnPro

J2506

CC-0002

Preferred

Udenyca

Q5111

TNAGP-CD-023940-23-CPN23712 _23-0536

PUBLICATIONS: August 2023 Provider Newsletter