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Medical Injectables Program Updates

Horizon collaborates with Magellan Rx Management (MRxM) to administer its Medical Injectables Program (MIP). As part of our shared commitment to help ensure that the medications our members need are medically necessary and cost effective, the following changes will be made to our MIP.

  • Use New HCPCS Code for Neulasta®
    Based on Centers for Medicare & Medicaid Services’ (CMS) guidance, please use HCPCS code J2506 when submitting Prior Authorization & Medical Necessity Determination (PA/MND) requests and claims for Neulasta® (pegfilgrastim) for services provided on and after January 1, 2022.

  • Medical Necessity and Appropriateness Review
    Beginning with services provided on and after April 1, 2022, MRxM will also conduct medical necessity and appropriateness reviews (MNAR) for the following injectable medications as part of the MIP.

    Medication Brand Name Generic Medication Name HCPCS Code
    Rylaze™ Asparaginase erwinia chrysanthemi (recombinant)-rywn J9021
    Rybrevant™ amivantamab-vmjw J9061
    Jemperli dostarlimab-gxly J9272
  • MRxM Claim Review
    The medical injectable drug code listed below, when included on claims for services rendered on and after April 1, 2022, will also be reviewed by MRxM to ensure the billing details are appropriate per our medical policy guidelines. This code/drug is not subject to MNAR.

    Medication Brand Name Generic Medication Name HCPCS Code
    Camcevi™ Leuprolide J1952

    If you have any questions, please contact your Network Specialist or Ancillary Contracting Specialist.

  • Reminders:
    As part of our MIP, MRxM conducts MNARs for injectable medications administered in a freestanding or hospital-based dialysis center, an outpatient facility, a patient’s home or a physician’s office. MRxM does not conduct MNARs for injectable medications administered during an inpatient stay, or in an Emergency Room or Observation Room setting.

    For medical Injectable services rendered in the patient’s home, call 1-855-243-3321 for participating Horizon Care@Home health care professionals to obtain pre-service determination.

  • We encourage you to review the medical policy criteria and guidelines for the injectable medications included as part of the MIP within our Medical Policy Manual.

Magellan Rx Management℠ is a service mark of Magellan Health, Inc. Magellan Rx Management is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the administration of conduct medical necessity and appropriateness review (MNAR) for certain medical injectable drugs. Magellan Rx Management is independent from and not associated with Horizon Blue Cross Blue Shield of New Jersey.

This web page contains prescription brand name drugs that are registered marks or trademarks of pharmaceutical manufacturers that are not affiliated with Magellan Rx Management, Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association.

Published on: December 29, 2021, 23:03 p.m. ET
Last updated on: December 28, 2021, 22:46 p.m. ET