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Medical Injectables Program Updates: September 2022

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

Medical Necessity and Appropriateness Review (MNAR) of Additional Drugs

For services to be provided on and after September 1, 2022, MRxM will perform MNAR for the following additional injectable medications as part of the MIP.

For the unclassified drugs noted below, please also include the appropriate National Drug Code (NDC) when interacting with MRxM and when submitting your claims.

Apretude™ cabotegravir J3490 49702026423
Empaveli® pegcetacoplan J3490 73606001001
Enjaymo™ sutimlimab-jome J3590 80203034701
Fyarro™ sirolimus-albumin-bound J9331  
Kimmtrak® tebentafusp-tebn J9999 80446040101
Korsuva™ difelikefalin J0879  
Leqvio® inclisiran J1306  
Nexviazyme™ avalglucosidase alfa-ngpt J0219  
Nulibry® fosdenopterin J3490 73129000101
Releuko® fligrastim-ayow J3590 70121156807, 70121156907, 70121157007, 70121157107
Revcovi™ elapeademase-lvlr J3590 57665000201
Ryplazim® plasminogen, human-tvmh J2998  
Saphnelo™ anifrolumab-fnia J0491  
Susvimo™ ranibizumab J2779  
Tezspire™ tezepelumab-ekko J2356  
Tivdak® tisotumab vedotin-tftv J9273  
Vabysmo® faricimab-svoa J3590 50242009601
Vyvgart efgartigimod Alfa J9332  
Zynlonta® loncastuximab tesirine J9359  

MRxM Claim Review

The medical injectable drug codes listed below, when included on claims for services rendered on and after September 1, 2022, will be reviewed by MRxM to ensure the billing details are appropriate per our medical policy guidelines. These codes are not subject to MNAR.

Brand Name Generic Name HCPCS
Byooviz™ ranibizumab-nuna Q5124
Durysta Implant® bimatoprost implant J7351
Retisert® fluocinonide acetonide intravitreal implant J7311
Iluvien® fluocinonide acetonide intravitreal implant J7313
Yutiq® fluocinonide acetonide intravitreal implant J7314
Ozurdex® dexamethasone intravitreal implant J7312
Dextenza® dexamethasone ophthalmic insert J1096
Xiaflex® Collagenase clostridium histolyticum J0775
Ilaris® canakinumab J0638
Xipere™ Triamcinolone acetonide injectable suspension J3299
  • 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.

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

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.

Published on: May 30, 2022, 08:57 a.m. ET
Last updated on: May 27, 2022, 04:20 a.m. ET