Two medical drugs going on commercial site-of-care program, starting April 1

Starting April 1, 2020, the site of care program for specialty drugs covered under the medical benefit is expanding. This applies to Blue Cross Blue Shield of Michigan and Blue Care Network commercial members for the following drugs:

• Hemlibra^® (emicizumab-kxwh, HCPCS code J7170)
• Onpattro^® (patisiran, HCPCS code J0222)

What to do by April 1
Before April 1, encourage your patients who have commercial coverage to select one of the following infusion locations instead of using a hospital outpatient facility:

• A doctor’s office or other health care provider’s office
• An ambulatory infusion center
• The member’s home, from a home infusion therapy provider

If members currently receive infusions for these drugs at a hospital outpatient facility, providers must:

• Obtain prior authorization for that location.
• Check the directory of participating home infusion therapy providers and infusion centers to see where the member may be able to continue infusion therapy.

If the infusion therapy provider can accommodate the member, they’ll work with the member and the member’s practitioner to make this change easy. The member may also contact the ordering practitioner directly for help with the change.

More about authorization requirements
The authorization requirements apply only to groups currently taking part in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don’t apply to members covered by the Federal Employee Program^® Service Benefit Plan.

Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list.

You can also find the list on either of the two following ereferrals.bcbsm.com webpages:

• Blue Cross Drugs Covered Under the Medical Benefit
• BCN Drugs Covered Under the Medical Benefit

We’ll update the requirements list for these drugs before April 1.