As new drugs and technologies become available, many of these treatments come with a very high cost. Many of these therapies now cost more than $1 million for one treatment. In an effort to control rising health insurance premiums, while continuing to make these therapies available to our members, certain drugs or therapies are subject to specific benefit, administration, and billing requirements.
Effective January 1, 2021, we formalized contract language to create specific benefit requirements for these very high cost drugs and therapies. These requirements may steer members to more cost-effective, yet equally safe administration facilities, may require billing from specific providers, or may require billing under either the pharmacy or medical benefit.
Our case management team assists our members with ensuring these requirements are met. Learn more about case management and how their program benefits our members.
For the most current list of very high cost drugs and therapies, you can review the program details below.
| Brand Name | Generic Name | HCPCS Code | Route of administration | What does this drug treat? | Does this drug have to be billed by a specific provider or company? | Does this drug have to be given in a specific facility? | Is this drug billed under pharmacy or medical benefit? |
|---|---|---|---|---|---|---|---|
| Luxturna | Voretigene neparvovec | J3398 | Intraocular (subretinal) | Treatment of confirmed biallelic RPE65 mutation-associated retinal dystrophy | Yes. This drug must be billed by a facility or specialty pharmacy that is directly contracted with BCBSKS, either through medical contracts or Letter of Agreement. | Yes. Spark Therapeutics has designated Ocular Gene Therapy Treatment Centers. Billing requirements must also be met. | Medical |
| Zolgensma | Onasemnogene abeparvovec | J3399 | Intravenous | Treatment of pediatric patients <2 years of age with spinal muscular atrophy (SMA) with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene | Yes. This drug must be billed by a facility or specialty pharmacy that is directly contracted with BCBSKS, either through medical contracts or Letter of Agreement. | Yes. Must be given at a Zolgensma treatment center. Billing requirements must also be met. | Medical |
