January 2023
Xenpozyme and Spevigo to have site-of-care requirements for most commercial members, starting in March
For dates of service on or after March 1, 2023, we’re adding site-of-care requirements for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under the medical benefit:
- Xenpozyme (olipudase alfa), HCPCS code J3590
- Spevigo (spesolimab-sbzo), HCPCS code J3590
The NovoLogix® online tool will prompt you to select a site of care when you submit prior authorization requests for these drugs. If the request meets clinical criteria for the drug, it will be approved automatically if it’s for one of the following sites of care:
- Doctor’s or other health care provider’s office
- Ambulatory infusion center
- The member's home, administered by a home infusion therapy provider
Additional information or documentation may be required for requests to administer Xenpozyme or Spevigo in an outpatient hospital setting.
As a reminder, these drugs already require prior authorization; providers can submit prior authorization requests using NovoLogix. The new site-of-care requirements are in addition to the current prior authorization requirements.
Members who start courses of treatment with Xenpozyme or Spevigo before March 1, 2023, will be able to continue receiving the drug in their current location until their existing authorization expires. If those members then continue treatment under a new prior authorization, the site-of-care requirements outlined above will apply.
Some Blue Cross commercial groups not subject to these requirements
For Blue Cross commercial groups, the prior authorization and site-of-care requirements apply only to groups that 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 March 1, 2023.
You can access this list and other information about requesting prior authorization on ereferrals.bcbsm.com at these locations:
As a reminder, authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. |