Update: Starting March 1, changes coming to site-of-care-requirements for Blue Cross commercial and BCN commercial pediatric members

This message was originally posted on Dec. 1, 2020. On Dec. 8, we updated this message to correct the date through which pediatric members who begin therapy at a hospital outpatient location before March 1 are authorized to continue treatment at the current location.

Beginning March 1, 2021, site-of-care exemptions will no longer apply to pediatric Blue Cross commercial members and pediatric Blue Care Network commercial members for some drugs covered under the medical benefit.

This means all drugs that have site-of-care requirements for adult commercial members will have the same site-of-care requirements for pediatric commercial members starting March 1.

For these drugs:

• Pediatric members who begin therapy at a hospital outpatient location before March 1 are authorized to continue treatment at the current location through Aug. 31, 2021. This will provide continuity of care and give members time to work with their providers during the transition period.
• Pediatric members who begin therapy on or after March 1 must have an authorization that includes a site-of-care approval. Members should talk to their doctors before March 1 to arrange to receive infusion services at one of the following locations:
  • Doctor's office or other health care provider's office
  • Ambulatory infusion center
  • The member's home

  Notes

  • Pediatric members who begin therapy on or after March 1 will be authorized to receive the first dose at a hospital outpatient facility.
  • If a member requires treatment in a hospital outpatient setting, the provider must submit clinical documentation to establish medical necessity; the plan will review the documentation and make a determination.

Definition of pediatric members

Pediatric members are defined as one of the following:

• 15 years old or younger, regardless of weight
• 16 through 18 years old who weigh 50 kg or less

More about the authorization requirements

• These authorization requirements apply only to groups that currently participate in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.
• Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

How to submit authorization requests

Submit authorization requests through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, do the following:

• For BCN commercial members: Click BCN and then click Medical Benefit Drugs. In the BCN HMO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.
• For Blue Cross commercial members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross PPO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.

Lists of requirements

To view requirements for these drugs, see the following drug lists:

• Standard commercial medical drug program: Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document
• 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)