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Medical Injectables Program Updates: Medications Added and Unlisted Code Allowances

Effective March 18, 2019, additional injectable medications¹ will be included as part of our Medical Injectables Program (MIP) administered by Magellan Rx Management℠.

Beginning with services to be provided on and after March 18, 2018, Magellan Rx Management will conduct medical necessity and appropriateness reviews (MNARs) for the following additional injectable medications when these injectable medications are administered in a freestanding or hospital-based dialysis center, an outpatient facility, a patient’s home or a physician’s office.¹

Brand Name Generic Name HCPCS
Aralast NP alpha-1-proteinase inhibitor J0256
Glassia alpha-1-proteinase inhibitor J0257
Zemaira alpha-1-proteinase inhibitor J0256
Somatuline Depot lanreotide J1930
Signifor LAR pasireotide long acting J2502

Review the full list of injectable medications that require MNAR as part of the MIP, or learn more about our Medical Injectables Program.

UNLISTED CODE ALLOWANCES
Also effective beginning March 18, 2019, Horizon BCBSNJ will change the methodology we use to calculate the allowance for injectable drugs submitted on claims using unlisted procedure codes.

The allowance for injectable medications submitted with HCPCS codes J3490, J3590 or J9999 on claims for services rendered on and after March 18, 2019 will be calculated based on the current Average Wholesale Price (AWP) of the drug in question minus 15 percent.

If you have questions, please contact your Network Specialist.

¹Medical necessity and appropriateness review is not required for injectable medications that are administered during an inpatient stay, or in an Emergency Room setting 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.

Magellan Rx Management℠ is a service mark of Magellan Health, Inc.

Published on: December 17, 2018, 10:36 a.m. ET
Last updated on: December 17, 2018, 14:38 p.m. ET