We're adding site-of-care requirements for Avsola^™, Reblozyl^® and Tepezza^™ for Blue Cross' PPO members, starting July 1

On July 1, 2020, we're adding site-of-care requirements for the following specialty drugs covered under the medical benefit, for Blue Cross' PPO (commercial) members:

• Avsola (infliximab-axxq, HCPCS code J3590)
• Reblozyl (luspatercept-aamt, HCPCS code J3590)
• Tepezza (teprotumumab-trbw, HCPCS code J3590)

Currently, J3590 is the HPCS code for Avsola, Reblozyl and Tepezza. On July 1, 2020, these drugs will be assigned to the following HCPCS codes: Avsola Q5121, Reblozyl J0896 and Tepezza C9061.

These drugs already require authorization.

What you need to do by July 1

• For Blue Cross' PPO members starting new courses of treatment with these drugs: Encourage them to select one of the following infusion locations (instead of an outpatient hospital facility):
  • A doctor's or other health care provider's office
  • An ambulatory infusion center
  • The member's home, from a home infusion therapy provider
• For Blue Cross' PPO members who currently receive infusions of these drugs at a hospital outpatient facility: Check the directory of participating home infusion therapy providers and infusion centers to see where the member may be able to continue infusion therapy.

  If the infusion therapy provider can accommodate the member, they'll work with you and the member to make this change easy. The member may also contact you, as the ordering practitioner, directly for help with the change.

• For Blue Cross' PPO members who aren't candidates to receive these drugs at a site other than an outpatient hospital facility: You must fax documentation that supports this medical necessity to the Pharmacy Clinical Help Desk. These requests will be evaluated on a case-by-case basis. See the Inquiries about drugs covered under the medical: Frequently asked questions for providers document for information about contacting the Help Desk.

  If members receive these drugs at an outpatient hospital facility without approval from Blue Cross, the members will be responsible for the full cost of the drugs.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program^® Service Benefit Plan.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on the Blue Cross Medical Benefit Drugs - Pharmacy page of this website.

We'll update the requirements list for these changes prior to July 1.

Posted: June 2020
Line of business: Blue Cross Blue Shield of Michigan