Site of Service Medical Policy – Infusions and Injectables and Preauthorization Lists Updates Starting July 15, 2024

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Site of Service Medical Policy – Infusions and Injectables and Preauthorization Lists Updates Starting July 15, 2024

04/16/2024

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 

 

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