Medical Policy Update: Site of Administration for Infusion and Injectable Prescription Medications
Horizon Blue Cross Blue Shield of New Jersey is implementing an update to our Site of Administration for Infusion and Injectable Prescription Medications medical policy to include the infusion drug ravulizumab-cwz (Ultomiris™). This change is effective January 22, 2020.
Claims for services provided on and after January 22, 2020 to Horizon BCBSNJ members who live in New Jersey and receive treatment with ravulizumab-cwz (Ultomiris™) will be processed according to the guidelines of the updated medical policy. Authorizations for services that are approved prior to January 22, 2020 will be honored through the approval period noted in the original authorization.
We strongly encourage you to review this medical policy, which contains a full listing of the included injectable and infusion drugs, in our Medical Policy Manual.
The guidelines of this medical policy apply to all 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 & Supports program]
- Medicare Advantage plans [i.e., Horizon Medicare Blue (PPO), Horizon Medicare Blue Access Group (HMO-POS), Horizon Medicare Blue Advantage (HMO), Horizon Medicare Blue Choice (HMO), Horizon Medicare Blue Group (PPO), Horizon Medicare Blue Select (HMO-POS), Horizon Medicare Blue Value (HMO)]
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 January 22, 2020.
According to the guidelines of our Site of Administration for Infusion and Injectable Prescription Medications medical policy, administration of the drugs identified in the policy in a hospital outpatient setting is considered not medically necessary in the vast majority of cases as more cost-effective settings are available. Administration in the hospital outpatient department will be considered medically necessary in the following clinical circumstances:
- Hospital outpatient administration of the IV infusion and/or injectable drugs is medically necessary for up to a 60-day duration only as initial treatment for new patients OR for patients re-initiating therapy after a period of at least six months of discontinuation of therapy to monitor for adverse reactions.
- An outpatient IV infusion or injectable therapy service in a hospital outpatient department is considered medically necessary only when the patient meets criteria identified in the medical policy, including:
Inherent complexity of the infusion such that it can be performed safely and effectively only by or under the supervision of physician; AND
Potential changes in the member's clinical condition are such that immediate access to specific services of a hospital setting, having emergency resuscitation equipment and personnel, and inpatient admission or intensive care is necessary.
For a complete list of criteria for medical necessity, please refer to Site of Administration for Infusion and Injectable Prescription Medications 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.