Clarification of site of administration requirements for FCA and GM commercial members using select infusion drugs
The following is a clarification of an earlier news item on this topic.
Requirements for FCA and GM members only (employer groups 100181 and 100355). Effective with therapy that starts on or after Jan. 1, 2016:
- Authorization is required only for BCN commercial (non-Medicare) members with coverage through Fiat Chrysler Automobiles (employer group 100181) and General Motors (employer group 100355) when the drugs listed below are administered at an infusion center with a location code of 19 or 22.
- No authorization is required for these members when the therapy is administered at other locations (at the physician's office, at the member's home or at an infusion center that's not affiliated with a hospital (that is, an infusion center with a location code other than 19 or 22).
The drugs are:
- Orencia® (procedure code J0129)
- Remicade® (procedure code J1745)
- Tysabri® (procedure code J2323)
No authorization is required at all for other (non-FCA and non-GM) BCN members for these drugs.
The BCN Referral/Clinical Review Program is being updated to reflect this new requirement more accurately. The revised document will be available at the end of January at ereferrals.bcbsm.com, on the Clinical Review & Criteria Charts page.
Reminder related to other medications. Authorization is required for a number of other medications covered under the medical benefit for all BCN commercial members, including those covered through FCA and GM. For additional information on the requirements for these medications, please refer to the BCN Referral/Clinical Review Program document.
Posted: January 2016
Line of business: Blue Care Network