We're adding site-of-care requirements for Uplizna® for Blue Cross commercial members, starting Jan. 1, 2021
Starting Jan. 1, 2021, we're adding site-of-care requirements for the following drug covered under the medical benefit for Blue Cross commercial members:
What you need to do
Encourage your patients who have Blue Cross commercial coverage to select one of the following infusion locations instead of using a hospital outpatient facility:
If members currently receive infusions for these drugs at a hospital outpatient facility, providers must:
Override for infusions received from Jan. 1 through Feb. 18
If a member who has a prior authorization that doesn't include a site-of-care requirement receives an infusion of Uplizna at an outpatient hospital facility from Jan. 1 through Feb. 18, 2021, the claim will be rejected for a noncovered site of care. However, you'll be able to receive an override for these dates of service so the claim will pay. To inquire about an override, call the Pharmacy Clinical Help Desk at 1-800-437-3803.
For dates of service on or after Feb. 19, all members must receive infusions at a covered infusion location, unless the provider obtains prior authorization for receiving the infusion at a hospital outpatient facility location.
More about authorization requirements
These authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.
Note: Uplizna already has site-of-care requirements for BCN commercial members for dates of service on or after Aug. 1, 2020.
Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.
List of requirements
For requirements related to drugs covered under the medical benefit, see the:
This change doesn’t apply to:
Posted: January 2021
Line of business: Blue Cross Blue Shield of Michigan