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

Here’s important information we communicated Nov. 1 in a web-DENIS message:

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan is adding three preauthorized medical drugs to the site of care requirement for members. Infusions for these drugs won’t be covered at hospital outpatient facilities without prior authorization for an approved location, starting Jan. 1.

The authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization program for drugs administered under the medical benefit. These changes don’t apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members.

All drugs included in this program already need prior authorization for payment. Approved authorizations will be payable for professional locations, with no further action required:

• Physician’s offices or other health care provider’s offices
• Ambulatory infusion centers
• The member’s home, from a home infusion therapy provider

Members must receive their infusions in a professional office setting, a professional infusion center or in the member’s home.

If your patient currently receives one of these infusions at a hospital outpatient facility:

• Submit a prior authorization request for your patient to Blue Cross for a hospital outpatient facility. If this request isn’t submitted and approved, the patient will be responsible for the full cost of the medicine.
• Find out where your patient can continue his or her infusion therapy. Check the directory of participating home infusion therapy providers and infusion centers. Please confirm network participation for your patient before his or her infusion.
• Tell your patient to contact any of the listed infusion therapy providers. If they’re able to accommodate your patient, they’ll work with you and your patient to make the change easy. We’re also sending this information to your patient.
• Help your patient switch his or her infusion therapy to your office, infusion center or home infusion therapy provider by Jan. 1.

For the ordering provider:
If a member must receive one of these infusions in a hospital outpatient facility, follow the normal steps for a prior authorization request and include:

• The authorization number previously approved
• Rationale that clearly describes the reason the infusion must be administered in a hospital setting
• Supporting chart notes

The medical drugs subject to this requirement include:

For more information about hospital outpatient infusion therapy, view previous issues of The Record:

2017
October
December

2018
March
June