We’ve added site-of-care requirements for Adakveo, Givlaari for Blue Cross’ PPO members

The site-of-care program for specialty drugs covered under the medical benefit has expanded as of April 1, 2020. This applies to Blue Cross Blue Shield of Michigan’s PPO members for the following drugs:

• Adakveo^® (crizanlizumab-tmca, HCPCS code C9053)
• Givlaari^® (givosiran, HCPCS code C9056)

Providers should encourage Blue Cross’ PPO members to select one of the following infusion locations instead of an outpatient hospital facility:

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

If Blue Cross’ PPO 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, the provider will 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 the authorization requirements

The authorization requirements apply only to groups that are currently participating 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 document located on the Blue Cross Medical Benefit Drugs – Pharmacy webpage of our ereferrals.bcbsm.com website.