Additional drugs to have site-of-care requirements for some commercial members starting in March

Starting March 15, 2024, the following medical benefit drugs will have a site-of-care requirement for Blue Cross Blue Shield of Michigan group and individual commercial members:

• Bavencio^® (avelumab), procedure code J9023
• Imfinzi^® (durvalumab), procedure code J9173
• Imjudo^® (tremelimumab-actl), procedure code J9347
• Jemperli™ (dostarlimab-gxly), procedure code J9272
• Keytruda^® (pembrolizumab), procedure code J9271
• Libtayo^® (cemiplimab-rwic), procedure code J9119
• Opdivo^® (nivolumab), procedure code J9299
• Opdualag™ (nivolumab and relatlimab-rmbw), procedure code J9298
• Tecentriq^® (atezolizumab), procedure code J9022
• Yervoy^® (ipilimumab), procedure code J9228
• Zynyz™ (retifanlimab-dlwr), procedure code J9345

The new site-of-care requirement means these drugs may be covered only when administered in the following locations:

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

These drugs already require prior authorization through the Oncology Value Management program, administered by Carelon Medical Benefits Management. The new site-of-care requirements are in addition to the current prior authorization requirements.

Members affected by this change

The following Blue Cross commercial members are affected by this change:

• All fully insured group and individual members, except for MESSA members
• Members who have coverage through self-funded groups that have opted in to the Oncology Value Management program. Note: Although UAW Retiree Medical Benefits Trust non-Medicare plans include this program, the site-of-care requirement doesn’t apply.

This requirement doesn’t apply to Medicare Plus Blue℠ and BCN Advantage℠ members or members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.

How requirement will be phased in

The site-of-care requirement will apply as follows for infusions involving the drugs listed above:

• For courses of therapy starting on or after March 15, 2024: These infusions may not be covered at outpatient hospital facilities.
• For courses of therapy that start before and continue beyond March 15, 2024:
• These infusions may not be covered at outpatient hospital facilities starting June 15, 2024.
• To continue treatment at an outpatient hospital facility, you’ll need prior authorization approval from Carelon before June 15.

What to do for members who currently receive these drugs

• For Blue Cross commercial members who currently receive these drugs at an outpatient hospital facility:
• Locate an in-network home infusion therapy provider or ambulatory infusion center at which the member may be able to continue the infusion therapy.
• Discuss with the member how to facilitate receiving the infusions at an allowed site of care.
• For Blue Cross commercial members who currently receive these drugs at a doctor’s office, at home or in an ambulatory infusion center, no action is required.

How we’ll help

For members who need to transition to a new infusion location, we’ll work with you and the member to facilitate the transition. We’ll notify members and:

• Encourage them to talk to you before changing their infusion location.
• Let them know that the change of location doesn’t affect the treatment you’re providing.

List of requirements

To view requirements for drugs covered under medical benefits, refer to the Blue Cross and BCN utilization management medical drug list for Blue Cross and BCN commercial members. We’ll update this list prior to the effective date.

You can access this list and other information about submitting prior authorization requests to Carelon on the Blue Cross Medical Benefit Drugs page at ereferrals.bcbsm.com.

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.