5/20/2024 Correction: We will only be adding 168 medications. The infusion site of care rules will not apply to Qalsody, J Code 1304 or Spinraza, J Code 2326.
Starting July 15, 2024, we will be updating our Site of Service Medical Policy – Infusions and Injectables to add 170 medications and remove the age restrictions so the policy will apply to all commercial members, not just those over the age of 21. We are modifying our protocols to ensure that injectable and infusion medications are administered at the most clinically appropriate site of care.
These drugs already require preauthorization. However, they may no longer be covered when administered in a hospital setting and may require administration in a member’s home or other outpatient location. We are making this change to expand the successes we are seeing in lowering members' out of pocket costs and providing convenient access to care for ongoing maintenance infusion services.
Routine maintenance for these additional drugs will be covered in the following settings:
- Home (POS 12)
- Office (POS 11)
- Ambulatory Infusion Suites (POS 24, POS 49, or POS 12 with Modifier SS)
Exceptions for initial doses for members with justifiable needs may be allowed if medical necessity criteria is met. A mailing will be sent to you with additional information if our records show you have patients with current authorizations from Express Scripts’ company Care Continuum (CCUM) so we can coordinate care.
After you contact CCUM for preauthorization, we will reach out to you to discuss a convenient location for your patient.
Medications That Will Be Added To Site of Service Medical Policy – Infusions and Injectables Starting July 15, 2024
|
HCPCS Code |
Drug |
|---|---|
|
J0801 |
Acthar |
|
J0802 |
Acthar |
|
J0791 |
Adakveo |
|
J9042 |
ADCETRIS |
|
J0172 |
Aduhelm |
|
J7192 |
Advate/Recombinate/Helixate/Helixate FS |
|
J7207 |
Adynovate |
|
J7210 |
Afstyla |
|
J1931 |
Aldurazyme |
|
J9305 |
ALIMTA |
|
J9322 |
Alimta |
|
J9323 |
Alimta |
|
J0256 |
Alpha 1 proteinase inhibitors Prolastin-C, Aralast NP, Zemaira) |
|
J7186 |
Alphanate |
|
J7193 |
AlphaNine SD |
|
J7201 |
Alprolix |
|
Q5126 |
ALYMSYS |
|
J1426 |
Amondys 45 |
|
J0225 |
Amvuttra |
|
J0256 |
Aralast NP, Prolastin, Zemaira |
|
C9257 |
Avastin |
|
J3145 |
Aveed |
|
J9023 |
Bavencio |
|
J7195 |
BeneFIX |
|
J0597 |
Berinert |
|
J9039 |
Blincyto |
|
J9041 |
Bortezomib (Velcade) |
|
J9048 |
BORTEZOMIB (Fresenius Kabi) |
|
J9049 |
BORTEZOMIB (Hospira) |
|
J0741 |
Cabenuva |
|
J0202 |
Campath/Lemtrada |
|
J0598 |
Cinryze |
|
J7175 |
Coagadex |
|
J7180 |
Corifact |
|
J0584 |
Crysvita |
|
J9308 |
Cyramza |
|
J0850 |
Cytogam |
|
J9144 |
Darzalex Faspro |
|
J9063 |
Elahere |
|
J1743 |
Elaprase |
|
J9217 |
Eligard |
|
J7205 |
Eloctate |
|
J9176 |
Empliciti |
|
J9358 |
Enhertu |
|
J1302 |
Enjaymo |
|
J7204 |
Esperoct |
|
J3111 |
Evenity |
|
J1305 |
Evkeeza |
|
J1428 |
Exondys 51 |
|
J9393 |
Faslodex |
|
J9394 |
Faslodex |
|
J9395 |
Faslodex |
|
J7198 |
Feiba NF |
|
J1951 |
Fensolvi |
|
J1744 |
Firazyr |
|
Q5130 |
Flynetra |
|
J9210 |
Gamifant |
|
J9301 |
Gazyva |
|
J0223 |
Givlaari |
|
J0257 |
Glassia |
|
J7170 |
Hemlibra |
|
J7190 |
Hemofil M |
|
J9355 |
Herceptin |
|
J9356 |
Herceptin Hylecta |
|
Q5113 |
Herzuma |
|
J7187 |
Humate-P |
|
J7202 |
Idelvion |
|
J9173 |
Imfinzi |
|
J9347 |
Imjudo |
|
J7213 |
Ixinity |
|
J9272 |
Jemperli |
|
J7208 |
Jivi |
|
J9354 |
Kadcyla |
|
J1290 |
Kalbitor |
|
Q5117 |
Kanjinti |
|
J2840 |
Kanuma |
|
J9271 |
Keytruda |
|
J7190 |
Koate-DVI |
|
J7192 |
Kogenate-FS |
|
J7211 |
Kovaltry |
|
J2507 |
Krystexxa |
|
J9047 |
Kyprolis |
|
J1932 |
Lanreotide |
|
J1306 |
Leqvio |
|
J9119 |
Libtayo |
|
J2778 |
Lucentis |
|
J0221 |
Lumizyme |
|
J1950 |
Lupron Depot |
|
J3398 |
Luxturna |
|
J3397 |
Mepsevii |
|
J9371 |
Mepsevii |
|
J7190 |
Monoclate-P |
|
J7193 |
Mononine |
|
Q5107 |
Mvasi |
|
J1458 |
Naglazyme |
|
J2506 |
Neulasta Onpro |
|
J0219 |
Nexviazyme |
|
J7182 |
Novoeight |
|
J7189 |
NovoSeven RT |
|
J2796 |
Nplate |
|
J7209 |
Nuwiq |
|
J7188 |
Obizur |
|
Q5114 |
Ogivri |
|
J0222 |
Onpattro |
|
Q5112 |
Ontruzant |
|
J9299 |
Opdivo |
|
J9298 |
Opdualag |
|
J0224 |
Oxlumo |
|
J9177 |
Padcev |
|
J9306 |
Perjeta |
|
J9316 |
Phesgo |
|
J9309 |
Polivy |
|
J9204 |
Poteligeo |
|
J0885 |
Procrit/Epogen |
|
J7194 |
Profilnine SD |
|
J1304 |
Qalsody |
|
J1301 |
Radicava (edaravone IV) |
|
J7203 |
Rebinyn |
|
J0896 |
Reblozyl |
|
J7203 |
Recombinate |
|
Q5123 |
Riabni |
|
J7178 |
RiaSTAP |
|
J9311 |
Rituxan Hycela |
|
J7200 |
Rixubis |
|
J1449 |
Rolvedon |
|
J0596 |
Ruconest |
|
J2998 |
Ryplazim |
|
J0491 |
Saphnelo |
|
J9227 |
Sarclisa |
|
J7212 |
Sevenfact |
|
J2327 |
Skyrizi IV |
|
J2326 |
Spinraza |
|
J3358 |
Stelara |
|
Q5127 |
Stimufend |
|
J1961 |
Sunlenca |
|
J2860 |
Sylvant |
|
90378 |
Synagis |
|
J9022 |
Tecentriq |
|
J9380 |
Tecvayli |
|
J2356 |
Tezspire |
|
J9273 |
Tivdak |
|
Q5116 |
Trazimera |
|
J3315 |
Trelstar |
|
J7181 |
Tretten |
|
J9317 |
Trodelvy |
|
J1746 |
Trogarzo |
|
J7686 |
Tyvaso |
|
J2777 |
Vabysmo |
|
J9303 |
Vectibix |
|
Q5129 |
Vegzelma |
|
J9046 |
Velcade |
|
J9049 |
Velcade |
|
J9051 |
Velcade |
|
J9051 |
Velcade |
|
J1427 |
Viltepso |
|
J1322 |
Vimizim |
|
J7179 |
Vonvendi |
|
J3032 |
Vyepti |
|
J1429 |
Vyondys 53 |
|
J9332 |
Vyvgart |
|
J9334 |
Vyvgart |
|
J7183 |
Wilate |
|
J0218 |
Xenpozyme |
|
J2357 |
Xolair |
|
J7185 |
Xyntha |
|
J9228 |
Yervoy |
|
Q5118 |
Zirabev |
|
J3399 |
Zolgensma |
|
J1632 |
Zulresso |
|
J9345 |
Zynyz |
