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Update: Medical Policy Updates for Self-Administered Drugs Effective April 15, 2025
BCBS Texas·TX · Allergy & Immunology, Pulmonology·Medical Policy
Effective date
Apr 15, 2025
We identified it
Jan 12, 2026
Summary
Starting April 15, 2025, Blue Cross Blue Shield of Texas will require medical necessity review for four self-administered drugs (Fasenra, Tezspire, Nucala, and Xolair) when given in healthcare settings instead of patient self-administration. If not medically necessary for provider administration, these drugs will shift from medical benefit billing to pharmacy benefit coverage.
Action Required
Before April 15, 2025: Billing team must establish process to submit BlueApprovRSM requests with documentation for medical necessity when administering Fasenra, Tezspire, Nucala, or Xolair in healthcare settings. Update billing workflows to redirect non-medically necessary administrations to pharmacy benefit. Train providers on documentation requirements to justify in-office administration versus patient self-administration. Failure to obtain approval will result in claims being processed under pharmacy benefit instead of medical benefit.