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December 2019

Certain infusion drugs won’t be covered in outpatient hospitals, starting in January

Beginning Jan. 1, 2020, Blue Cross Blue Shield of Michigan is adding two more medical drugs to the commercial site of care requirement. The following medical drugs will be subject to this requirement:

  • Evenity®  (HCPCS code J3111)
  • Ultomiris® (HCPCS code J1303)

Infusions for these drugs won’t be covered at hospital outpatient facilities without prior authorization for an approved location, starting Jan. 1.

These changes don’t apply to BCN AdvantageSM, Medicare Plus BlueSM PPO or Federal Employee Program® members. The authorization requirement only applies to groups currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.
An approved authorization will be payable for any of these professional locations:

  • A doctor’s office or other health care provider’s office
  • Ambulatory infusion center
  • Your patient’s home, with treatment from a home infusion therapy provider

If health care providers don’t submit the appropriate prior approval requests and don’t receive approval for the outpatient hospital site of care, their patients will be responsible for the full cost of the medicine.  
Tell your patients to:

  • Contact any of the infusion therapy providers listed on their member letter on the site of care program. We mailed a letter to members on Oct. 30, explaining the program requirements for these drugs. The infusion therapy providers will work with members to make the change easy.
  • Log in to their member account at bcbsm.com and select Find a Doctor to locate therapy infusion providers.

For more information about hospital outpatient infusion therapy, read the following articles from earlier this year:

Certain infusion drugs won’t be covered in outpatient hospitals, starting Jan. 1

Certain infusion drugs won’t be covered in outpatient hospitals, starting April 1

We’re adding medical benefit specialty drugs to prior authorization and site of care programs for PPO members, starting Oct. 1

View The Record Archive for additional articles on this topic from 2018 and 2017.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.
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