We're adding two medical drugs to the PPO commercial site of care requirements starting in January

Beginning Jan. 1, 2020, Blue Cross Blue Shield of Michigan is adding site of care requirements for two medical drugs for Blue Cross' PPO members. The following two medical drugs and HCPCS codes are subject to this requirement:

• Evenity^® (romosozumab-aqqg; HCPCS code J3111)
• Ultomiris^® (ravilizumab-cwvz; HCPCS code J1303)

Infusions for these drugs won't be covered at hospital outpatient facilities without prior authorization for an approved location, starting Jan 1. An approved authorization will be payable for any of these professional locations:

• A doctor's office or other health care provider's office
• Ambulatory infusion center
• Your patient's home, with treatment from a home infusion therapy provider

These site of care requirements are already in place for BCN HMO^SM members.

This communication doesn't apply to members covered by BCN Advantage^SM, Medicare Plus Blue^SM PPO or the Federal Employee Program^®.

The authorization requirement applies only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

If providers don't submit the appropriate prior approval requests and receive approval for the outpatient hospital site of care, members will be responsible for the full cost of the medicine.

Tell members to contact any of the infusion therapy providers listed on their member letter. (We're also sending this information to members.) The infusion therapy providers will work with you and with members to make the change easy.

Posted: November 2019
Line of business: Blue Cross Blue Shield of Michigan