Reminder: Effective July 1, Krystexxa® and Stelara® (SQ/IV) are subject to a site-of-care requirement for BCN HMOSM (commercial) members

As a reminder, effective July 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

Brand name HCPCS code Generic name
Krystexxa J2507 pegloticase
Stelara (SQ/IV) J3357, J3358 ustekinumab

This requirement applies only to BCN HMO (commercial) members, for first-time and current users of these medications. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select medical benefit drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Krystexxa and Stelara (SQ/IV) must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Krystexxa and Stelara is included in the list that is now available online.

Posted: June 2018
Line of business: Blue Care Network