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Updates to the Medical Injectables Program: January 2021

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 January 1, 2021, MRxM will conduct medical necessity and appropriateness reviews (MNAR) for the following additional injectable medications as part of the MIP.

BRAND NAME GENERIC NAME HCPCS
Vyepti™ eptinezumab-jjmr J3032
Tepezza® teprotumumab-trbw J3241
Sarclisa® isatuximab-irfc J9227

MRxM 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.

To obtain pre-service determination of medical injectable services in the patient’s home , call 1-855-243-3321 for participating Horizon Care@Home.

We 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.

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.

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: October 1, 2020, 23:58 p.m. ET
Last updated on: September 30, 2020, 17:11 p.m. ET