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Medical Policy Implementation: Arsenic Trioxoide (Trisenox®)

Effective February 4, 2019, Horizon Blue Cross Blue Shield of New Jersey will change the way we process certain claims based on the guidelines of a new medical policy, Arsenic Trioxoide (Trisenox®).

Access our Medical Policy Manual to review this medical policy content.


Claims submitted for services provided on February 4, 2019 and after to patients enrolled in Horizon BCBSNJ Commercial, Administrative Services Only (ASO) and Medicare Advantage (MA)¹ plans will be processed as noted below.

  • Medical record information may be requested to help us determine the medical appropriateness of the injectable drug represented by HCPCS code J9017 included on claims.

    HCPCS code J9017 may be denied, based on the submitted diagnosis code(s) or following our review of medical record information, as an experimental/investigative, non-covered service.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims on and after February 4, 2019.

¹ The content of Horizon BCBSNJ medical policies that apply to services provided to Horizon BCBSNJ MA members may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). Horizon BCBSNJ follows Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and LCDs in our processing of claims for services provided to Horizon BCBSNJ MA members. For those services where no LCD or NCD exists, claims for services provided to MA members will be processed based on our policy guidelines.

Trisenox® is a registered trademark of Teva Pharmaceuticals.

Published on: November 5, 2018, 12:16 p.m. ET
Last updated on: November 11, 2018, 23:37 p.m. ET