Site-of-care requirement for Piasky and Tremfya (medical benefit)
Adds a site-of-care requirement (in addition to existing prior authorization) for Piasky (crovalimab-akkz) and Tremfya (guselkumab) administered under the medical benefit for most Blue Cross and BCN commercial members, effective for dates of service on or after June 1, 2025.
A site-of-care requirement was added for Piasky IV/SC (J1307) and Tremfya IV/SC (J1628) for most commercial members effective June 1, 2025.
Members who start treatment before June 1, 2025, may continue in their current location until existing authorization expires; thereafter new site-of-care rules apply.
Some Blue Cross commercial groups that do not participate in the standard commercial Medical Drug Prior Authorization Program are not subject to these requirements.
Coverage Criteria
These prior authorization and site-of-care requirements apply only to Blue Cross commercial groups that participate in the standard commercial Medical Drug Prior Authorization Program. Group participation is determined by the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list; providers should consult that list to confirm whether a given group is subject to the requirements.
Some groups do not participate in the standard prior authorization program and therefore are not subject to these rules. For example, UAW Retiree Medical Benefits Trust non‑Medicare members do not participate in the standard program but are subject to these requirements; Blue Cross and Blue Shield Federal Employee Program members are not subject to these requirements.
Coding (Medical Benefit HCPCS)
| J1307 | Piasky ® IV and SC (crovalimab-akkz) |
| J1628 | Tremfya ® IV and SC (guselkumab) |
Provider Actions and Prior Authorization
Site-of-care selection required
For dates of service on or after 2025-06-01, prior authorization requests for Piasky (crovalimab-akkz, J1307) and Tremfya (guselkmab, J1628) will prompt the provider to select a site of care at submission. Requests that meet clinical criteria and are for an approved site will be automatically approved. Approved sites: doctor's or other health care provider's office; ambulatory infusion center; member's home when provided by a home infusion therapy provider. Additional documentation may be requested for outpatient hospital administration. Members already receiving these drugs before 2025-06-01 may finish the course at their current site until existing authorization expires; the site-of-care requirement applies to any new authorization thereafter.
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