Medical Policy Revision: Alpha 1-Proteinase Inhibitors (Human)

Effective March 14, 2019, Horizon BCBSNJ will implement revisions to our medical policy Alpha 1-Proteinase Inhibitors (Human) [Prolastin-C®, Aralast NP®, Zemaira® and Glassia®].¹

These policy revisions will change the way we process certain claims for services provided to patients enrolled in Horizon BCBSNJ Commercial and Administrative Services Only (ASO) plans. We also will begin to process claims submitted for services provided to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans based on the content of this policy. (This policy has previously only applied to patients enrolled in Horizon BCBSNJ Commercial and ASO plans.)

Access our Medical Policy Manual to review this medical policy content.²

Claims submitted for services provided on and after March 14, 2019 will be processed as noted below.

• HCPCS codes J0256, J0257 and/or S9346 included on claims for services provided to patients 18 years of age and older may be denied, based on the submitted diagnosis code(s), as experimental/investigational, non-covered services.
   
• HCPCS codes J0256, J0257 and/or S9346 included on claims for services provided to patients younger than 18 years of age will be denied, regardless of the submitted diagnosis code(s), as experimental/investigational, non-covered services.

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 for services on and after March 14, 2019.

This document contains references to brand name prescription medicines that are trademarks or registered marks of pharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey, the Blue Cross and Blue Shield Association.

¹ A similar news item about a revision to this policy was posted in April 2018, but the changes announced were not implemented.

² The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.