Prolia^® and Xgeva^® won’t be covered in outpatient hospitals without approval, starting Oct. 1

Blue Cross Blue Shield of Michigan is adding two injectable drugs, Prolia and Xgeva, to the site of care requirement for members, beginning Oct. 1, 2018. These drugs won’t be covered at outpatient hospital facilities without prior authorization for the approved location, starting Oct. 1.

The authorization requirement only applies to groups currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

Approved locations for Prolia and Xgeva injections

• Doctor’s office – Members must receive their injections in the doctor’s office.
• Home infusion therapy – They’re only approved if received at the same time as an infusion by a home infusion therapy provider.
• Outpatient hospital facility – Members must receive a prior authorization for this location.

Both drugs in this program already require prior authorization for payment. Approved authorizations will be payable for professional locations such as physician’s offices and home infusions with no further action required.

Help your patient switch his or her injection therapy to your office by October 1.

If a member must receive one of these injections in a hospital outpatient facility, the ordering provider must follow the normal steps for a prior authorization request and include:

• The authorization number previously approved
• Rationale that clearly describes the reason the injection must be administered in a hospital setting
• Supporting chart notes

If this request isn’t submitted and approved, the patient will be responsible for the full cost of the medicine Oct. 1 or later.

For more information about hospital outpatient infusion therapy, view the previous articles in the October, December, March and June issues of The Record.

If you have questions, contact provider inquiry.