Additional drugs to have a site-of-care requirement for some commercial members, starting Aug. 1

For dates of service on or after Aug. 1, 2024, the following medical benefit drugs will have a site-of-care requirement for some Blue Cross Blue Shield of Michigan and all Blue Care Network group and individual commercial members:

When the site-of-care requirement goes into effect, these drugs may be covered only when administered at the following sites of care:

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

These drugs already require prior authorization through the Oncology Value Management program, administered by Carelon Medical Benefits Management. The new site-of-care requirement is in addition to any current prior authorization requirements.

Commercial members affected by this change

• Blue Cross commercial:
• All fully insured members (group and individual), with the exception of MESSA members
• 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 in to this program, the site-of-care requirement doesn’t apply.)

Note: This requirement doesn’t apply to members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.

• All Blue Care Network commercial members

How the site-of-care requirement will be phased in

The site-of-care requirement will apply as follows for infusions involving the drugs listed above:

• For courses of therapy starting on or after Aug. 1, 2024: These infusions may not be covered at outpatient hospital facilities.
• For courses of therapy that start before and continue beyond Aug. 1, 2024: These infusions may not be covered at outpatient hospital facilities starting Nov. 1, 2024. To continue treatment at an outpatient hospital facility, you’ll need to submit a prior authorization request to Carelon for approval prior to Nov. 1.

What to do for members who currently receive these drugs

For Blue Cross and BCN commercial members who currently receive these drugs at an outpatient hospital facility:

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

For Blue Cross and BCN commercial members who currently receive these drugs at a provider’s office, at home or in an ambulatory infusion center, no action is required.

How we’ll help

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.

List of requirements

• To view requirements for drugs covered under the medical benefit, refer to the Blue Cross and BCN utilization management medical drug list for Blue Cross and BCN commercial members. We’ll update this list prior to the effective date on Aug. 1.
• You can access this list and other information about submitting prior authorization requests to Carelon at ereferrals.bcbsm.com on the following pages:
• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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