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Medical Injectables Program Updates: May 2021

Horizon BCBSNJ 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.

  • Medical Necessity and Appropriateness Review
    Beginning with services provided on and after May 17, 2021, MRxM will 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

Darzalex FasproTM

daratumumab and hyaluronidase-fihj

J9144

ExondysTM

eteplirsen

J1428

Jelmyto®

mitomycin

J9281

NyvepriaTM

pegfilgrastim-apgf

Q5122

PhesgoTM

pertruzumab, trastuzumab, and hyaluronidase-zzxf

J9316

Scenesse®

afamelanotide

J7352

Spravato®

esketamine

S0013

TrodelvyTM

sacituzumab govitecan-hziy

J9317

Uplinza®

inebilizumab-cdon

J1823

Vyondys

golodirsen

J1429

ZepzelcaTM

lurbinectedin

J9223

For Medicare Advantage members, please use the appropriate G code (G2082 or G2083) for esketamine rather than S0013.

  • Use New HCPCS Code for Sevenfact
    Based on Centers for Medicare & Medicaid Services’ (CMS) guidance and in accordance with the American Medical Association, please use HCPCS code J7212 when submitting Prior Authorization & Medical Necessity Determination (PA/MND) requests and claims for Sevenfact® [coagulation factor VIIa (recombinant)-jncw] for services provided after January 1, 2021.

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 ManagementSM 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 and Blue Shield Association.

Published on: February 15, 2021, 01:41 a.m. ET
Last updated on: February 16, 2021, 13:20 p.m. ET