Medical Injectables Program

Horizon Blue Cross Blue Shield of New Jersey is committed to providing your patients, our members, with access to high-quality health care services that are consistent with nationally recognized clinical criteria and guidelines.

As part of that commitment, Horizon BCBSNJ collaborates with Magellan Rx Management, a specialty pharmaceutical management company to administer our Medical Injectables Program (MIP). Magellan Rx Management conducts medical necessity and appropriateness reviews (MNARs) for specific injectable medications.

List of injectable medications and HCPCS codes included as part of our MIP

Out of Network Consent Form
As part of this program, and in compliance with our Out-of-Network Referral Policy¹, referring/prescribing doctors who plan to use a nonparticipating specialty pharmacy or home health care provider for drugs/services for a member enrolled in a Horizon BCBSNJ plan that includes out-of-network benefits must complete a copy of a new MIP-specific version of our Consent for Referral to an Out-of-Network Provider form.

Complying with the guidelines of our Out-of-Network Referral Policy helps ensure that members enrolled in plans with out-of-network benefits are made aware in advance when referring/prescribing doctors plan to use a nonparticipating provider. The policy also helps ensure that members understand their potential out-of-pocket costs when using a nonparticipating provider.

Hemophilia Drugs
Since August 15, 2019, Magellan Rx Management conducts medical necessity and appropriateness review (MNAR) for hemophilia drugs.

• Review the complete list of injectable medications (including hemophilia products) that are subject to MNAR as part of this program
• Review FAQs specific to Hemophilia Drugs

Hemophilia Case Review Form
As part of this program, rendering providers of hemophilia products must complete a Hemophilia Case Review Form prior to the dispensing of the first dose and prior to the dispensing of subsequent doses that will document:

• Original prescription information
• Requested amount to be dispensed (including specific vial sizes
• Vial sizes available
• Patient clinical history (including patient product inventory and bleed history)

This case review process will help ensure appropriate administration of medication, assay management, inventory management and patient engagement, as well as helping ensure that bleed history is appropriately documented and tracked.

RESOURCES

• Medical Injectables Program FAQs
• Hemophilia Drugs FAQs
• Member Referral Consent Form: Using an Out-of-Network Provider for Medical Injectable Drugs
• Access our Medical Policies Manual to view clinical criteria and guidelines related to medical injectables, including hemophilia products.
• Review the Quick Start Guide; step-by-step instructions to help ordering physicians and their staff obtain medical necessity determinations for the specialty medical injectable medications included in this program.
• Review the Quick Reference Guide which provides the high-level information you need to know about Horizon BCBSNJ’s MIP.

¹To access our Out-of-Network Referral Policy, log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:

• Mouse over References and Resources and select Provider Reference Materials.
• Mouse over Policies and Procedures and select Policies.
• Select Administrative Policies.