Enhanced Editing Affecting Drugs & Biological Agents

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will be instituting a new reimbursement policy for various drugs and biological agents effective January 17, 2023. We will be implementing enhancements to our claims processing system that reflect guidelines set forth by industry authorities in order to process claims consistently and in accordance with best practice standards.  

The new policy will enforce guidelines regarding appropriate indications for use, dosing limits, and frequency of use.  

• Only FDA-approved indications and acceptable off-label indications are covered. 
  
• These indications are used to confirm diagnosis validity, dosage, and frequency of dosing.   

The primary source for the policy is the manufacturer’s package insert (FDA approved indications).  Other references include but are not limited to sources such as the DrugPoints®, which replaces the United States Pharmacopoeia Dispensing Information (USP DI), the American Hospital Formulary Service Drug Information® (AHFS DI) and CMS publications. 

Important Notes 

• This policy will begin for any claims with date of service 01/17/2023 and later. 
  
• This policy will not affect your reimbursement / payment amounts. Services will be paid at the same rates as they previously were.  
• These policies will apply to professional and facility claims. There are no changes to any processes, including claims submission, customer service and support, or grievances and appeals. 

Review Medicare and commercial reimbursement policy notifications.

This communication applies to State Health Plan (SHP), Administrative Services Only (ASO), Fully Insured, Senior Market Administration (SMA), and IPP Host. It does not apply to FEP or IPP Home claims.