Reminder: Effective Oct. 1, Prolia® and Xgeva® are subject to a site-of-care requirement for BCN HMOSM members

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

For both medications, the generic name is denosumab and the HCPCS code is J0897.

The site-of-care requirement applies only to BCN HMO (commercial) members. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select 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 Prolia and Xgeva must meet applicable authorization criteria in addition to the site-of-care requirement. This applies to first-time and current users of these medications.

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 Prolia and has been added to the list.

Posted: September 2018
Line of business: Blue Care Network