We’ve added site‑of‑care requirements for Uplizna for Blue Cross commercial members

Effective Jan. 1, 2021, Blue Cross Blue Shield of Michigan has added site‑of‑care requirements for Uplizna^® (inebilizumab‑cdon), HCPCS code J1823. This drug is covered under the medical benefit for our commercial members.

Encourage your patients who have Blue Cross 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 receiving the infusion at a hospital outpatient facility location.
• Check the directory of participating home infusion therapy providers and infusion centers to see where the member can continue receiving infusion therapy. To do this, go to bcbsm.com, click on Find a Doctor, click on the Search without logging in link, click on Places by type, enter Home infusion therapy or Ambulatory infusion therapy center in the search field and press the Enter key.

Override for infusions received from Jan. 1 through Feb. 18
If a member had a prior authorization that didn’t include a site‑of‑care requirement and received an infusion of Uplizna at an outpatient hospital facility from Jan. 1 through Feb. 18, 2021, the claim will be rejected for a noncovered site of care.

However, you can receive an override for these dates of service so the claim will pay. To inquire about an override, call the Pharmacy Clinical Help Desk at 1‑800‑437‑3803.

For dates of service on or after Feb. 19, all members must receive infusions at a covered infusion location, unless the provider obtains prior authorization for receiving the infusion at a hospital outpatient facility location.

More about authorization requirements
These authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

Note: Uplizna already has site‑of‑care requirements for Blue Care Network commercial members for dates of service on or after Aug. 1, 2020.

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

List of requirements
For requirements related to drugs covered under the medical benefit, review these resources:

• Blue Cross and BCN utilization management medical drug list
• UAW Retiree Medical Benefits Trust non‑Medicare members: Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non‑Medicare members
• Blue Cross and Blue Shield Federal Employee Program^® non‑Medicare members: Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members

Additional information
This change doesn’t apply to:

• BCN Advantage℠ members
• Medicare Plus Blue℠ members