Medical Policy Revision: XIAFLEX (collagenase clostridium histolyticum)

Effective July 11, 2018, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for Xiaflex®.

We encourage you to visit our Medical Policy Manual to review the guidelines of our medical policy, XIAFLEX (collagenase clostridium histolyticum), which identify when the use of this drug is considered medically necessary.

Based on the guidelines included in our medical policy, XIAFLEX (collagenase clostridium histolyticum), claims for services provided on and after July 11, 2018 will be processed as follows:

• Claims for services provided to patients age 18 and over that include HCPCS codes J0775 may, based on the submitted diagnosis code(s), pend while information to help us determine the medical necessity of this drug is requested and reviewed.

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 dates of service on and after July 11, 2018.

XIAFLEX® is a registered trademark of Endo Pharmaceuticals Inc.