Loqtorzi to have requirements for most members, starting Aug. 15

For dates of service on or after Aug. 15, 2024, Loqtorzi™ (toripalimab-tpzi), HCPCS code J3263, will have the following requirements through the Oncology Value Management program:

• For Blue Cross Blue Shield of Michigan and Blue Care Network commercial members: Loqtorzi will have both a prior authorization requirement and a site-of-care requirement.
• For Medicare Plus Blue℠ and BCN Advantage℠ members: Loqtorzi will have a prior authorization requirement.

The Oncology Value Management program is administered by Carelon Medical Benefits Management. These drugs are part of members’ medical benefits, not their pharmacy benefits.  

Prior authorization requirement

Prior authorization requirements apply when these drugs are administered in outpatient settings for:

• Blue Cross commercial
• All fully insured members (group and individual)
• Members who have coverage through self-funded groups that have opted in to the Oncology Value Management program. (Although UAW Retiree Medical Benefits Trust non-Medicare plans have opted into this program, these requirements may not apply; refer to their medical oncology drug list, which is linked below.)
  Note: This requirement doesn’t apply to members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.
• Medicare Plus Blue members
• BCN commercial members
• BCN Advantage members

Site-of-care requirement

For the commercial members listed above, this drug may be covered only when administered at the following sites of care for dates of service on or after Aug. 15:

• Doctor’s or other health care provider’s office
• The member's home, administered by a home infusion therapy provider
• Ambulatory infusion center

Here’s what to do for commercial members who receive Loqtorzi at an outpatient hospital facility for dates of service before Aug. 15:

• Locate an in-network home infusion therapy provider or ambulatory infusion center at which the member may be able to continue infusion therapy.
• Discuss with the member how to facilitate receiving infusions at an allowed site of care.

For members who need to transition to a new infusion location, we’ll work with you and the member to facilitate the transition. We’ll notify members and encourage them to talk to you before changing their infusion location. We’ll also let them know that the change of location doesn’t affect the treatment you’re providing.

How to submit prior authorization requests

Submit prior authorization requests to Carelon using one of the following methods:

• Through the Carelon provider portal, which you can access by doing one of the following:
• Logging in to our provider portal (availity.com),** clicking on Payer Spaces and then clicking on the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space, where you’ll click the Carelon ProviderPortal tile.
  Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.
• Logging in directly to the Carelon provider portal at providerportal.com.**
• By calling the Carelon Contact Center at 1-844-377-1278

Drug lists

For additional information on requirements related to drugs covered under medical benefits, refer to the following drug lists:

• Blue Cross commercial and BCN commercial:
• Oncology Value Management program prior authorization list for Blue Cross and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• Oncology Value Management program prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date.

As a reminder, prior authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.