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March 2019

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

Beginning April 1, 2019, Blue Cross Blue Shield of Michigan is adding six pre-authorized 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 April 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 AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.

Approved authorizations are payable for the following professional locations:

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

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 the infusion therapy provider can 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 April 1.

For the ordering provider:

If a member must receive one of these infusions in a hospital outpatient facility, please 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:

Drug name

HCPCS

Crysvita®

J0584

Fasenra

J0517

Ilumya

J3245

Mepsevii

J3397

Radicava®

J1301

Trogarzo

J1746

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

2017
October
December

2018
March
June
September

2019
January

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

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