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Updates to the Medical Injectables Program

Horizon BCBSNJ collaborates with Magellan Rx Management (MRxM) to administer its Medical Injectables Program (MIP). As part of our shared commitment to help ensure the drugs our members need are medically necessary and cost effective, the following changes will be made to our MIP.

Medical Necessity and Appropriateness Review
Beginning with services to be provided on and after October 1, 2020, MRxM will conduct medical necessity and appropriateness reviews (MNAR) for the following additional injectable medications as part of the MIP¹

BRAND NAME GENERIC NAME HCPCS
Adakveo® crizanlizumab-tmca J0791
Asceniv™ IV immune globulin J1599
Avsola® infliximab-axxq J7169
Cutaquig® subcutaneous immune globulin 90284
Enhertu® fam-trastuzumab deruxtecan-nxki J9358
Esperoct® antihemophilic factor (recombinant), glycopegylated-exei J7204
Evomela® melphalan J9246
Folotyn® pralatrexate J9307
Givlaari® givosiran J0223
Istodax® romidepsin J9315
Ixempra® ixabepilone J9207
Padcev® enfortumab vedotin-ejfv J9177
Proleukin® aldesleukin J9015
Reblozyl® luspatercept-aamt J0896
Ruxience® rituximab-pvvr Q5119
Xembify® subcutaneous immune globulin J1558
Ziextenzo® pegfilgrastim-bmez Q5120

MRxM Claim Review
The medical injectable drug codes listed below, when included on claims for services rendered on and after October 1, 2020, will be reviewed by MRxM to ensure the billing details are appropriate per our medical policy guidelines.²These codes are not subject to MNAR.

BRAND NAME GENERIC NAME HCPCS
Eligard® leuprolide acetate (for depot suspension) J9217
Firmagon® degarelix J9155
Lupron Depot® leuprolide acetate (for depot suspension) J1950
Supprelin LA® histrelin J9226
Trelstar® triptorelin pamoate J3315
Triptodur® triptorelin J3316
Vantas® histrelin acetate J9225
Zolodex® goserelin acetate implant J9202

Use New HCPCS Codes Effective July 1, 2020

Based on Centers for Medicare & Medicaid Services’ guidance and in accordance with the American Medical Association, effective July 1, 2020, please use the HCPCS codes noted below for Infugem™ (gemcitabine) and Visco-3™ (hyaluronan or derivative).

Brand Name Generic Name New HCPCS
Infugem™ gemcitabine J9198
Visco-3™ hyaluronan or derivative J7333

Thank you for your continued cooperation, especially as we navigate the current health care environment.

If you have any questions, please contact your Network Specialist or Ancillary Contracting Specialist.

¹As part of our MIP, Magellan Rx Management conducts MNARs for injectable medications administered in a freestanding or hospital-based dialysis center, an outpatient facility, a patient’s home or a physician’s office. Magellan Rx Management does not conduct MNARs for injectable medications administered during an inpatient stay, or in an Emergency Room or Observation Room setting.

For medical Injectable services rendered in the patient’s home, call
1-855-243-3321 for participating Horizon Care@Home health care professionals to obtain pre-service determination.

²We encourage you to review the medical policy criteria and guidelines for the injectable medications included as part of the MIP within our Medical Policy Manual.

Magellan Rx Management is a service mark of Magellan Health, Inc. Magellan Rx Management is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the administration of conduct medical necessity and appropriateness review (MNAR) for certain medical injectable drugs. Magellan Rx Management is independent from and not associated with Horizon Blue Cross Blue Shield of New Jersey.

This web page contains prescription brand name drugs that are registered marks or trademarks of pharmaceutical manufacturers that are not affiliated with Magellan Rx Management, Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

Published on: June 30, 2020, 21:30 p.m. ET
Last updated on: June 30, 2020, 12:15 p.m. ET