Additional medical benefit specialty drugs have authorization and site of care requirements for BCN HMOSM members, effective Oct. 1, 2019
Effective Oct. 1, 2019, additional medical benefit specialty drugs have authorization and site of care requirements for BCN HMOSM (commercial) members. These changes don't apply to BCN AdvantageSM members.
Prior authorization requirements
For members initiating therapy on or after Oct. 1, 2019, you must request authorization for these drugs:
- Lemtrada® (alemtuzumab, HCPCS code J0202)
- Ocrevus® (ocrelizumab, HCPCS code J2350)
- Tysabri® (natalizumab, HCPCS code J2323)
Members who currently receive these drugs in one of the following locations are authorized to continue treatment through Sept. 30, 2020:
- Doctor's or other health care provider's office
- The member's home, from a home infusion therapy provider
- Ambulatory infusion center
- Hospital outpatient facility (Lemtrada and Tysabri ONLY)
However, you'll need to request authorization for these members for therapy that begins on or after Oct. 1, 2020, for these services to be eligible for reimbursement.
Site of care requirement for Ocrevus
Ocrevus will also be added to the Site of Care Program, effective Oct. 1, 2019. If your patient currently receives Ocrevus infusions at an outpatient hospital facility, you may need to discuss other infusion options.
As part of our shared commitment to keeping health care affordable for all, we hope you will join us in supporting our members as they move to new therapy locations.
List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on this website.
We'll update the requirements list to reflect the changes for these drugs.
Blue Cross Blue Shield of Michigan and Blue Care Network reserve the right to review for medical necessity prior to the effective dates listed in this message. A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.
As a reminder, you can always find information about authorization requirements for these drugs on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website.