Medical Injectables Program

As part of this program, and in compliance with our Out-of-Network Referral Policy, 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 plan that includes out-of-network benefits must fill our Member Referral Consent Form: Using an Out-of-Network Provider for Medical Injectable Drugs.

Complying with the Out-of-Network Referral Policy helps ensure that members enrolled in plans with out-of-network benefits have advance notice they will use a nonparticipating provider. The policy also helps ensure that members understand their potential out-of-pocket costs when using a nonparticipating provider.

To 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

Rendering providers of hemophilia products must complete and submit our 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 medications and bleed history)

Access ourHemophilia Case Review Form.

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

Below is information about the process we will follow in regard to the inclusion of new-to-market (NTM) drugs within our Medical Injectables Program (MIP).

• An online news item will be posted within News & Legal Notices to provide at least 30 days' advance notice before a NTM drug is added to the MIP.


• The NTM drug (and the corresponding not otherwise classified HCPCS code and NDC number) will be added to our list of Injectable Medications subject to Medical Necessity and Appropriateness Review (MNAR).


• When a procedure code is assigned to a NTM drug included in our MIP, we will update the online list of Injectable Medications subject to MNAR to replace the NOC code and NDC number.


• The assignment of a HCPCS code to an NTM drug included in our MIP will not be announced. Providers should access the publicly available HCPCS Quarterly Update information on CMS.gov to understand when HCPCS codes are assigned.


• Until medical policy guidelines may be developed, published and announced online within our Medical Policy Manual, our approach to NTM drugs will be based solely on prescribing information (packet insert).

Access our Medical Policies Manual to view clinical criteria and guidelines related to medical injectables, including hemophilia products.