Medical Policy Implementation: Site of Administration for Infusion and Injectable Prescription Medications
Horizon Blue Cross Blue Shield of New Jersey is implementing a new medical policy for drugs administered in a hospital outpatient setting, effective May 7, 2018.
Claims for services provided on and after May 7, 2018 submitted for Horizon BCBSNJ members living in New Jersey and receiving treatments of the drugs listed below at a hospital outpatient facility will be processed according to the guidelines of our new medical policy, Site of Administration for Infusion and Injectable Prescription Medications. We strongly encourage you to review this policy in our Medical Policy Manual. Authorizations for services that are approved prior to the May 7, 2018 effective date of this medical policy will be honored through the approval period noted in the original authorization.
The guidelines of this medical policy apply to all Horizon BCBSNJ plans/products, except as noted below:
- BlueCard® (please contact the member’s local BCBS Plan regarding requirements)
- Federal Employee Program®
- Horizon NJ Health plans [Medicaid Managed Care, NJ Family Care, Horizon NJ TotalCare (HMO SNP), Managed Long Term Services and Supports program]
- Medicare Advantage plans, including State Health Benefits Program Medicare Advantage (MA) PPO
According to the guidelines of our Site of Administration for Infusion and Injectable Prescription Medications medical policy, the administration of the infusion and injectable therapy drugs listed below in a hospital outpatient setting is considered not medically necessary except as follows:
- Hospital outpatient administration of the IV infusion and/or injectable drugs listed below is medically necessary for up to a 60-day duration only as initial treatment for new start patients OR for patients re-initiating therapy after a period of at least six months of discontinuation of therapy unless a patient meets certain criteria as identified in the medical policy.
| Medications affected by this change: |
| infliximab (RemicadeTM) |
| infliximab-dyyb (InflectraTM) |
| infliximab-abda (RenflexisTM) |
| infliximab-qbtx (IxifiTM) |
| tocilizumab (ActemraTM) |
| certolizumab pegol (CimziaTM) |
| abatacept (OrenciaTM) |
| vedolizumab (EntyvioTM) |
| golimumab (Simponi AriaTM) |
| ustekinumab (StelaraTM) |
- An outpatient IV infusion or injectable therapy service in a hospital outpatient department or hospital outpatient clinic level of care setting for the use of an infused pharmacologic or biologic agent is considered medically necessary only when the patient meets criteria identified in the medical policy.
- Other uses of outpatient IV infusion and injectable therapy services in the hospital outpatient department or hospital outpatient clinic level of care for the infusion of pharmacologic and biologic agents are considered not medically necessary.
Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after May 7, 2018.
This information contains prescription brand name drugs that are registered marks or trademarks of pharmaceutical manufacturers that are not affiliated with either Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.
The BlueCard® names and symbols, Federal Employee Program® and FEP® names are registered marks of the Blue Cross and Blue Shield Association.
