CurrentEmpire BluecrossPolicy N/A

Site of Care Drug List — Medical Benefit Specialty Drugs

Lists specialty drugs that, when covered under the medical benefit, require a site-of-care clinical review per Anthem's clinical utilization management guidelines. Affects providers submitting medical claims for the listed J-/Q-/C-codes.

Policy Summary

PayerEmpire Bluecross

PolicySite of Care Drug List — Medical Benefit Specialty Drugs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain a site-of-care clinical review per Anthem guidelines when administering listed specialty drugs billed under the medical benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~250drug HCPCS/Codes listed

site-of-care requiredclinical review

medical benefitapplies to

multi-statecoverage scope

Coverage Criteria

Site-of-Care Clinical Review Requirement

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The list of specialty drugs and HCPCS codes in this document is provided for informational purposes and does not guarantee benefits. Providers and billing staff should verify coverage on the payer drug list and in the member's benefit plan prior to furnishing or billing for any drug.

The list may change without notice, which could affect benefit coverage. Always confirm current coverage determinations and applicable utilization management requirements (for example, the site-of-care clinical review requirement referenced elsewhere in this policy) before delivering services.

Provider Actions & Requirements

Documentation Required

Site-of-Care Clinical Review Required

Site-of-care clinical review is required for the specialty drugs listed when covered under the medical benefit. Providers must follow Anthem's clinical utilization management/site-of-care clinical review process when administering these specialty drugs. Failure to obtain the required site-of-care clinical review may result in utilization management actions, including denial or noncoverage.

Applies to specialty drugs covered under the medical benefit
Failure to obtain site-of-care clinical review may trigger utilization management actions

Prior Authorization

No prior authorization requirements are described in the provided excerpts.

Note

Provider Actions — Authorization/Denial Triggers

None specified in this section; no authorization or denial triggers are described in the available excerpts.

Step Therapy

No step therapy requirements are described in the provided excerpts.

Note

Complaint Filing / Civil Rights Notice

Members may file complaints (grievances) in writing to the Compliance Coordinator at P.O. Box 27401, 23279. Members may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F HHH Building; Washington, D.C. 20201, by calling 1-800-368-1019 (TDD: 1-800-537-7697), or online at https://ocrportal.hhs.gov/ocr/portal. Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html.

Compliance Coordinator, P.O. Box 27401, 23279
HHS OCR: 200 Independence Avenue, SW; Room 509F HHH Building; Washington, D.C. 20201
HHS OCR phone: 1-800-368-1019 (TDD: 1-800-537-7697)
OCR portal: https://ocrportal.hhs.gov/ocr/portal
Complaint forms: https://www.hhs.gov/ocr/office/file/index.html

Documentation Required

Documentation and Review Requirements

Providers must follow Anthem's clinical utilization management/site-of-care clinical review process when administering the specialty drugs listed. This includes initiating the site-of-care clinical review prior to administration when required.

Follow Anthem's clinical utilization management/site-of-care clinical review process
Initiate site-of-care clinical review prior to administration when required

Prior Authorization

Prior Authorization (placeholder)

No prior authorization requirements are described in these excerpts.

Definitions & Language Access

Language access and nondiscrimination — civil rights protections and interpreter/translation services information

Nondiscrimination policyWe follow federal civil rights laws and do not discriminate based on race, color, national origin, sex, age or disability.

Language assistanceFree language assistance services (interpreters and written translations) are offered for people whose primary language is not English.

Disability accommodationsFree aids and services are provided for people with disabilities to ensure access to health program information and activities.

How to file a grievanceMembers may file a complaint in writing to the Compliance Coordinator at P.O. Box 27401, 23279.

Federal complaint optionComplaints can also be filed with the U.S. Department of Health and Human Services, Office for Civil Rights (200 Independence Ave SW, Room 509F, Washington, D.C. 20201) or by calling 1-800-368-1019 (TDD: 1-800-537-7697) or online at the HHS OCR portal.

J3262	Actemra
J0791	Adakveo
J7192	Advate, Kogenate-FS, Recombinate
J7207	Adynovate
J7171	Adzynma
J7210	Afstyla
J1931	Aldurazyme
J7186	Alphanate
J7193	AlphaNine SD, Mononine
J7201	Alprolix

J0597	Berinert
J1556	Bivigam
Q5152	Bkemv
J2329	Briumvi
J0741	Cabenuva
J1566	Carimune Nanofiltered, Gammagard S/D
J1786	Cerezyme
J0717	Cimzia
J2786	Cinqair
J0598	Cinryze

OpenPayer

Site of Care Drug List — Medical Benefit Specialty Drugs

Coverage Criteria

HCPCS / Billing Codes

Provider Actions & Requirements

Definitions & Language Access

Site-of-Care Guidance