Oct. 17, 2024
Effective Jan. 1, 2025, we’re updating our medical policies for self-administered drugs. Starting Jan. 1, 2025, we will review the medical necessity of administering drugs in a health care setting when they could appropriately be self-administered. This will include the policies for drugs FDA-approved for self-administration, including Fasenra (benralizumab), Tezspire (tezepelumab), Nucala (mepolizumab) and Xolair (omalizumab).
What’s changing? Blue Cross and Blue Shield of New Mexico medical policies for Fasenra (benralizumab), Tezspire (tezepelumab), Nucala (mepolizumab) and Xolair (omalizumab) will include coverage criteria for determining when administration in a health care setting is medically necessary for these products. If it’s determined that administration of these drugs in a health care setting is not medically necessary, the products should be self-administered and will be processed under the pharmacy benefit.
Member notification: We’ll notify impacted members who are currently being treated with these drug products under the medical benefit and administered in a health care setting.
The details: Pharmacy benefit coverage guidelines will continue to apply. These may include:
- Limits to filling a 30-day supply at a time for specialty drugs
- Limits to using a network specialty pharmacy for maximum benefit coverage
- Added requirements applied to the drug for coverage, such as prior authorization approval or dispensing limits
Coverage guidelines are based on the member’s benefit plan.
You should know: If it is medically necessary for a member to continue having a self-injectable drug administered in a health care setting, you will need to submit a request through BlueApprovRSM for continued coverage under the member’s medical benefit. Documentation is required, and we will review based on our medical policies. Drugs approved to be administered by a provider should be billed under the medical benefit.
More information: Information about prior authorization can be found on the Utilization Management section of our provider website. Information about medical criteria can be found on our Medical Policies page.
Always check eligibility and benefits first for each member at every visit. This step confirms membership and other details, such as prior authorization requirements and utilization management vendors, if applicable.
If your patients have questions, they can call the number on their member ID card or log on to Blue Access for MembersSM.
BCBSNM contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSNM, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
The relationship between BCBSNM and the specialty pharmacies is that of independent contractors.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a provider. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.