Medical Policy Update: Site of Administration for Infusion and Injectable Prescription Medications – Expanded

Effective December 1, 2018, Horizon BCBSNJ is including additional infusion and injectable drugs within the guidelines of our medical policy, Site of Administration for Infusion and Injectable Prescription Medications.

As a result of this policy update, Horizon BCBSNJ will change the way we consider claims submitted for the administration of the following infusion and injectable drugs on and after December 1, 2018. This applies to Horizon BCBSNJ members living in New Jersey and who are receiving treatments of the drugs at a hospital outpatient facility.

Infusion/injectable drugs affected by this update:

• Belimumab (Benlysta®)
• Eculizumab (Soliris®)
• Human C1 Inhibitor (Cinryze®)
• Laronidase (Aldurazyme®)
• Galsulfase (Naglazyme®)
• Idursulfase (Elaprase®)
• Imiglucerase (Cerezyme®)
• Taliglucerase alfa (Elelyso®)
• Velaglucerase alfa (Vpriv®)
• Agalsidase beta (Fabrazyme®)
• Alglucosidase alfa (Lumizyme®)
• Intravenous immune globulin (Bivigam®, Carimune® NF, Flebogamma®, Gammagard® S/D, Gammaplex®, Gamunex®, Octagam®, Privigen®)
• Subcutaneous immune globulin (Cuvitru®, Gammagard® liquid, Hizentra ®, Hyqvia®)

We strongly encourage you to review this medical policy in our Medical Policy Manual.

According to the guidelines of our Site of Administration for Infusion and Injectable Prescription Medications medical policy, the administration of certain infusion and injectable therapy drugs 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 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.

• 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.

Authorizations for the drugs listed above that are approved prior to December 1, 2018 will be honored through the approval period noted in that 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® (FEP®)
• 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

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 December 1, 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 Blue Shield Association.

The BlueCard® names and symbols, Federal Employee Program® and FEP® names are registered marks of the Blue Cross Blue Shield Association.