We're adding site-of-care requirements for Adakveo® and Givlaari® for Blue Cross' PPO members starting April 1
The site of care program for specialty drugs covered under the medical benefit is expanding starting April 1, 2020. This applies to Blue Cross' PPO (commercial) members for the following drugs:
- Adakveo (crizanlizumab-tmca, HCPCS code C9053)
- Givlaari (givosiran, HCPCS code C9056)
What to do by April 1
Providers should encourage Blue Cross' PPO members to select one of the following infusion locations instead of an outpatient hospital facility by April 1:
- A doctor's or other health care provider's office
- An ambulatory infusion center
- The member's home, from a home infusion therapy provider
If Blue Cross' PPO members currently receive infusions for these drugs at a hospital outpatient facility, providers must:
- Obtain prior authorization for that location
- Check the directory of participating home infusion therapy providers and infusion centers to see where the member may be able to continue infusion therapy
If the infusion therapy provider can accommodate the member, they'll work with the member and the member's practitioner to make this change easy. The member may also contact the ordering practitioner directly for help with the change.
More about the authorization requirements
The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.
Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.
List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO (PDF) document located on this website, on the Blue Cross Medical Benefit Drugs - Pharmacy webpage.
We'll update the requirements list for these drugs prior to April 1.
Posted: March 2020
Line of business: Blue Cross Blue Shield of Michigan