Piasky, Tremfya to have site-of-care requirement for most commercial members, starting June 1

For dates of service on or after June 1, 2025, we’re adding a site-of-care requirement for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under medical benefits:

• Piasky^® IV and SC (crovalimab-akkz), HCPCS code J1307
• Tremfya^® IV and SC (guselkumab), HCPCS code J1628

When you submit prior authorization requests for these drugs, you’ll be prompted to select a site of care. If the request meets the clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:

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

Additional information or documentation may be required for requests to administer Piasky or Tremfya in an outpatient hospital setting.

Please remember, these drugs already require prior authorization. The new site-of-care requirement is in addition to the current prior authorization requirement.

Members who start courses of treatment with Piasky or Tremfya before June 1, 2025, will be able to continue receiving these drugs in their current locations until their existing authorizations expire. If these members then continue treatment under new prior authorizations, the site-of-care requirement outlined above will apply.

Some Blue Cross commercial groups aren’t subject to these requirements

Prior authorization and site-of-care requirements apply only to Blue Cross commercial groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

While UAW Retiree Medical Benefits Trust non-Medicare members don’t participate in the standard prior authorization program, these requirements apply to them.

Note: These requirements don’t apply to Blue Cross and Blue Shield Federal Employee Program^® members.

Lists of requirements

For more information about requirements related to drugs covered under medical benefits, see these lists:

• Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare members

We’ll update these lists before the effective date.

You can access these lists 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

Prior authorization isn't a guarantee of payment. Health care providers need to verify eligibility and benefits for members.