Modifiedblue cross blue shield - michiganPolicy N/A

Provider alert

Announces a site-of-care requirement for Yesintek (HCPCS Q5100) for most Blue Cross Blue Shield of Michigan and Blue Care Network commercial members for dates of service on or after 2025-09-01; describes prior authorization submission behavior, automatic approvals for certain sites, exceptions, and group participation nuances.

Policy Summary

Payerblue cross blue shield - michigan

PolicyProvider alert

Policy CodePolicy N/A

Change TypeSite-of-care requirement

Effective DateSep 1, 2025

Next Review Date

Key ActionWhen requesting prior authorization for Yesintek on or after 2025-09-01, providers must select a site of care in the PA submission; requests meeting clinical criteria and using approved sites (office, ambulatory infusion center, home via home infusion therapy provider) will be approved automatically.

SourceLink

POLICY UPDATE CHANGES

Site-of-care requirement for Yesintek (Q5100) for most commercial members effective Sept. 1, 2025.

Grandfathering rule for members who start treatment before Sept. 1, 2025.

Group participation exceptions described.

1Drug affected

2025-09-01Effective date

May 29, 2025

What is changing

Blue Cross Blue Shield of Michigan is adding a site-of-care requirement for medical-benefit administered Yesintek (HCPCS Q5100) for dates of service on or after Sept. 1, 2025, and providers will be prompted to select a site of care when submitting prior authorization requests.

When a prior authorization request meets clinical criteria and the selected site is a doctor's or other health care provider's office, an ambulatory infusion center, or the member's home (via a home infusion therapy provider), the request will be approved automatically; requests for the outpatient hospital setting may require additional information or documentation.

Members who start Yesintek before Sept. 1, 2025 may continue receiving it at their current location until their existing authorization expires; if treatment continues under a new prior authorization after expiration, the site-of-care requirement applies.

The requirement applies only to groups participating in the standard commercial Medical Drug Prior Authorization Program (see the Specialty Pharmacy Prior Authorization Master Opt-in/out list); some Blue Cross commercial groups are not subject to the requirement, UAW Retiree Medical Benefits Trust non-Medicare members are included, and the requirement does not apply to Blue Cross and Blue Shield Federal Employee Program members.

Key facts

Drug affectedYesintek (HCPCS Q5100)

Effective date2025-09-01

Notice postedMay 29, 2025

Applies toMost BCBSM and BCN commercial members participating in standard Medical Drug PA Program; excludes FEP; includes UAW Retiree non‑Medicare members

Coverage criteria and rules

Site-of-care requirement for Yesintek (Q5100)

For dates of service on or after Sept. 1, 2025, prior authorization requests for Yesintek will require selection of site of care; approvals follow these rules:

ALL of the following

Drug is Yesintek IV or SC (ustekinumab-kfce), HCPCS Q5100
ALL of the following
- Approved automatically when site of care is ONE of: Doctor's or other health care provider's office
- Approved automatically when site of care is ONE of: Ambulatory infusion center

Coding affected

Drug HCPCSHCPCSCovered

Q5100

Yesintek (ustekinumab-kfce) IV and SC

Action required for providers

Prior Authorization

Select site of care when submitting PA

When requesting prior authorization for Yesintek on or after 2025-09-01, providers must select a site of care in the PA submission; requests that meet clinical criteria and use an approved site (office, ambulatory infusion center, or home via a home infusion therapy provider) will be approved automatically.

Q5100
office
ambulatory infusion center
home (home infusion therapy provider)

Documentation Required

Additional documentation for outpatient hospital setting

Requests to administer Yesintek in an outpatient hospital setting may require additional information or documentation to obtain approval.

Definitions

Yesintek: Trade name for ustekinumab-kfce covered under HCPCS Q5100 for IV and SC administration.

Yesintek is billed under HCPCS code Q5100.

Policy changes

2025-09-01policy_change_effective

For dates of service on or after Sept. 1, 2025, a site-of-care requirement applies for Yesintek (ustekinumab-kfce), HCPCS Q5100, for most Blue Cross Blue Shield of Michigan and Blue Care Network commercial members; PA submissions must include a site-of-care selection and requests meeting clinical criteria for office, ambulatory infusion center, or home infusion will be approved automatically; outpatient hospital settings may require additional documentation.

2025-09-01grandfathering

Members who start Yesintek treatment before Sept. 1, 2025, may continue receiving the drug at their current location until their existing authorization expires; if they continue treatment under a new prior authorization after expiration, the site-of-care requirement applies.

2025-09-01

Policy Summary

Payerblue cross blue shield - michigan

PolicyProvider alert

Policy CodePolicy N/A

Change TypeSite-of-care requirement

Effective DateSep 1, 2025

Next Review Date

SourceLink

On This Page

Approved automatically when site of care is ONE of: The member's home, from a home infusion therapy provider

If request is for outpatient hospital setting, additional information or documentation may be required

Grandfathering for existing authorizations

ALL of the following

Members who start Yesintek before 2025-09-01 may continue receiving it at their current location until existing authorization expires
If member continues treatment under a new prior authorization after expiration, the site-of-care requirement applies

Group participation exceptions

ANY of the following

Some Blue Cross commercial groups do not participate in the standard prior authorization program; site-of-care requirement does not apply to those non-participating groups
To determine participation, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list
UAW Retiree Medical Benefits Trust non-Medicare members: although they don't participate in standard PA program generally, the requirements apply to them
Requirements do not apply to Blue Cross and Blue Shield Federal Employee Program members

Clinical rationale
Cost justification

Billing Rule

Use Medical and Pharmacy Drug PA Portal

Submit prior authorization requests for Yesintek using the Medical and Pharmacy Drug PA Portal.

Denial Risk

Verify eligibility and benefits

Prior authorization is not a guarantee of payment; providers must verify member eligibility and benefits to avoid denials.

scope_exception_clarification

Site-of-care and prior authorization requirements apply only to groups participating in the standard commercial Medical Drug Prior Authorization Program; UAW Retiree Medical Benefits Trust non-Medicare members are covered by these requirements, and Blue Cross and Blue Shield Federal Employee Program members are excluded.

2025-05-29notice_postedLatest

Provider alert posted announcing the site-of-care requirement and related program details for Yesintek (Q5100) effective Sept. 1, 2025.