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Claim Processing Update: Self-Administered Injectable Medications

A recent review of claims revealed that certain specialty drugs that are to be self-administered (or administered by a caregiver who is not a health care professional) have been reimbursed under our patients’ medical benefits rather than under their prescription drug benefits.

Beginning January 1, 2021, the injectable medication drugs and drug categories noted below – when these drugs are to beself-administered or administered by a caregiver who is not a healthcare professional – will ONLY be considered for reimbursement under Horizon BCBSNJ prescription drug benefit plans.

Members should obtain these medications through a participating specialty pharmacy and take them to their doctor's office where they can receive medical supervision and/or instruction for administration, as appropriate.

  • Actemra SQ® (tocilizumab)²
  • Benlysta SQ® (belimumab)²
  • Cimzia® (certolizumab pegol)²
  • Dupixent® (dupilumab)¹
  • Fasenra® (benralizumab)²
  • Nucala® (mepolizumab)²
  • Orencia SQ® (abatacept)²
  • Stelara SQ® (ustekinumab)²

Authorizations for the drugs listed above that are approved prior to January 1, 2021, will be honored through the approval period noted in that authorization.

This change does not impact member benefits. Claims finalized before date will not be adjusted solely for the sole purpose of complying with this change.

We encourage you to access our online Medical Policy Manual to review our coverage guidelines for various medications/drugs.

¹ These drugs may have more than one formulation. The subcutaneous formulation should be obtained through a participating specialty pharmacy and reimbursed through a patient’s pharmacy benefit unless it is being administered by a healthcare professional in an office or home care setting.

² These drugs are included as part of our Medical Injectables Program. Please submit a request to Magellan Rx Management to conduct a medical necessity and appropriateness review (MNAR) for this injectable medication.

This information contains prescription brand name drugs that are registered marks or trademarks of pharmaceutical manufacturers that are not affiliated with either Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

Published on: October 1, 2020, 05:26 a.m. ET
Last updated on: September 30, 2020, 06:36 a.m. ET