Provider Reminder: Updates to Site of Care Expansion for Medical Infusion

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is working to help our members with complex medical conditions and get the care they need in the most cost-effective way. Costs for drug infusions are significantly higher when rendered in a hospital outpatient setting compared to other non-hospital settings. For this reason, Blue Cross NC is expanding our existing policy for certain provider-administered medications to be rendered at alternative locations to now include additional infusion medications. The policy, Place of Service for Medical Infusions (PDF), already applies alternative location guidelines for medications ordered within select therapeutic categories, including alpha-1 proteinase inhibitors, hereditary angioedema, multiple sclerosis, autoimmune and respiratory disorders.

Beginning October 1, 2021, Blue Cross NC members’ benefits and the availability of coverage for certain additional provider-administered medications may be limited to infusion services provided at non-hospital locations, unless the member is considered medically unstable or not clinically appropriate to receive infusions outside of a hospital setting. Blue Cross NC members considered medically stable may be required to receive certain provider-administered medications at approved locations, which include non-hospital outpatient centers, physicians’ offices, ambulatory and home infusion.

Any new or renewal authorization  requests for provider-administered medications and infusion services applicable to this policy that are provided at hospital outpatient locations,  will not be eligible for reimbursement under Blue Cross NC members’ benefits, unless approved in advance by Blue Cross NC.

Authorizations  

Blue Cross NC members who have existing authorizations and are currently receiving infusion services at outpatient hospital locations may continue to receive these infusions for the duration of the authorization. Any new or renewal authorization  requests for applicable infusion medications will be subject to the policy changes effective October 1, 2021, and a site outside of the outpatient hospital setting will need to be located at that time. Please work with your Blue Cross NC patients if changes to their locations for care are necessary.

Beginning October 1, 2021, the expanded site of care requirements contained in the 'Place of Service for Medical Infusions' policy will apply to any renewal authorization or new authorization request for the applicable infusion medications. Please note that following October 1, 2021, additional newly FDA approved infusion medications that are appropriate for site of care requirements may be added to the ‘Place of Service for Medical Infusions’ policy going forward.

Codes for medications being added to the policy include:

J0222, J0223, J0224, J0490, J0517, J0584, J0638, J0717, J0791, J0896, J1301, J1303, J1554, J1628, J1746, J1823, J1930, J2353, J2354, J2502, J2796, J3032, J3111, J3241, J3245, J3357, and J3358 

Medications without specific codes being added to the policy include:  

• Empaveli (pegcetacoplan) 
  
• Evkeeza (evinacumabdgnb)  
• Nulibry (fosdenopterin), 
• Prevymis (letermovir) 
• Ryplazim (plasminogen, human-tvmh) 

For additional information and detailed site of care requirements, please visit the Medical Policy page or the Prior Review and Limitations page to review Blue Cross NC’s revised Medical Policy for Place of Service for Medical Infusions (PDF). The site of care criteria can also be found within each individual medical policy for the applicable infusion medications, effective for Blue Cross NC members on October 1, 2021.  

For further assistance, please call our provider line at 800-672-7897.