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:

• Uplizna (inebilizumab-cdon), HCPCS code J1823

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:

• A doctor's office or other health care provider's office
• An ambulatory infusion center
• The member's home, from a home infusion therapy provider

If members currently receive infusions for these drugs at a hospital outpatient facility, providers must:

• Obtain prior authorization for receiving the infusion at the hospital outpatient facility 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. To do this, go to bcbsm.com, click Find a Doctor, click the Search without logging in link, click Places by type, enter Home infusion therapy or Ambulatory infusion therapy center in the search field and press ENTER.

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:

• Blue Cross and BCN utilization management medical drug (PDF) list
• UAW Retiree Medical Benefits Trust non-Medicare members: Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members (PDF)
• Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members: Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members (PDF)

Additional information

This change doesn’t apply to:

• BCN Advantage^SM members
• Medicare Plus Blue^SM members

Posted: January 2021
Line of business: Blue Cross Blue Shield of Michigan