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Site of Administration for Infusion and Injectable Prescription Medications Medical Policy

On October 1, 2020, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) will update our Site of Administration for Infusion and Injectable Prescription Medications Medical Policy to include additional infusion drugs administered in hospital outpatient settings. This change is part of our commitment to ensure our members receive safe and cost-effective medications they may need. The following drugs will be added:

Benralizumab (Fasenra®)
Lanreotide (Somatuline® Depot)
Mepolizumab (Nucala®)
Octreotide Acetate (Sandostatin® LAR Depot)
Omlizumab (Xolair®)
Patisran (Onpattro®)
Reslizumab (Cinqair®)

Claims for services provided on and after October 1, 2020 for Horizon BCBSNJ members who live in
New Jersey and receive treatments of the drugs listed in this table will be processed according to the guidelines of the updated medical policy. Authorizations for services that are approved prior to October 1, 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 at HorizonBlue.com/medicalpolicy.

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
    D-SNP), Managed Long Term Services & Supports
  • Medicare Advantage plans

Horizon BCBSNJ will provide written notice if all or part of the above changes have been canceled or postponed.

Policy Guideline Exceptions

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 in the policy 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 on the other side of this page 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 unless the 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.

We appreciate your cooperation, especially during these challenging times. If you have questions, please contact your Hospital Contracting Manager.

Published on: June 29, 2020, 03:13 a.m. ET
Last updated on: June 30, 2020, 05:49 a.m. ET