Oxlumo to have site-of-care requirement for commercial members beginning in October

Starting Oct. 1, 2022, Oxlumo^® (lumarisan), HCPCS code J0224, will have a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members.

When the site-of-care requirement goes into effect, this drug may be covered only when administered at the following sites of care:

• Doctor’s or other health care provider’s office
• Ambulatory infusion center
• The member's home, from a home infusion therapy provider

As a reminder, this drug already requires prior authorization; providers can submit prior authorization requests using the NovoLogix^® online tool. The new site-of-care requirement is in addition to the current prior authorization requirement.

Members who start treatment before Oct. 1, 2022, will be able to continue receiving the drug in their current location until their existing authorization expires. Providers should then transition members to one of the above sites of care.

Note: This drug is part of members’ medical benefits, not their pharmacy benefits.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ll update this list prior to Oct. 1.

You can access this list and other information about requesting prior authorization at ereferrals.bcbsm.com, at these locations:

• Blue Cross Medical Benefit Drugs page
• BCN Medical Benefit Drugs page

As always, authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.