Update: Medical Policy Updates for Self-Administered Drugs Effective April 15, 2025
AI 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.
Plan Types
Commercial
States
TX
Specialties
allergy-immunology, pulmonology