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Very High Cost Drugs and Therapies

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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 NameGeneric NameHCPCS CodeRoute of administrationWhat 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?
LuxturnaVoretigene neparvovecJ3398Intraocular (subretinal)Treatment of confirmed biallelic RPE65 mutation-associated retinal dystrophyYes. 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
ZolgensmaOnasemnogene abeparvovecJ3399IntravenousTreatment of pediatric patients <2 years of age with spinal muscular atrophy (SMA) with bi-allelic mutations in the survival motor neuron 1 (SMN1) geneYes. 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
RethymicAllogenic processed thymus tissue - agdcJ3590 or C9399ImplantCongenital athymiaYes. This drug must be billed by a facility that is directly contracted with BCBSKS, either through medical contracts or Letter of Agreement.Yes. Must be given by a qualified surgical team at a hospital certified to implant Rethymic.Medical
ZyntegloBetibeglogene autotemcelJ3590 or C9399IntravenousTreatment of beta thalassemia in patients who require regular transfusions.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 Zynteglo Qualified Treatment Center. Billing requirements must also be met.Medical
SkysonaElivaldogene autotemcelJ3590 or C9399IntravenousTo slow the progression of neurologic dysfunction in boys 4-17 years of age with early, active cerebral adrenoleukodysrophy (CALD)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 Skysona Qualified Treatment Center. Billing requirements must also be met.Medical
HemgenixEtranacogene dezaparvovecTBDIntravenousTreatment of hemophilia B (congenital factor IX deficiency) in adults who currently use factor IX prophylaxis therapy, have current or historical life-threatening hemorrhage, or have repeated, serious spontaneous bleeding episodes.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 Hemgenix treatment center. Billing requirements must also be met.Medical
RoctavianValoctocogene roxaparvovec-rvoxTBDIntravenousTreatment of adults with severe hemophilia A (congenital Factor VIII (FVIII) deficiency with FVIII activity <1IU/dL) without antibodies to adeno-associated virus serotype 5 (AAV5) as detected by an FDA-approved test.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.TBDMedical
ElevidysDelandistrogene moxeparvovec-roklTBDIntravenousTreatment of ambulatory pediatric patients aged 4 through 5 with Duchenne muscular dystrophy (DMD) with a confirmed mutation in the DMD 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.TBDMedical
VijuvekBeremagene-geperpavec-svdtTBDTopicalTreatment of wounds in patients 6 months of age and older with dystrophic epidermolysis bullosa with mutation(s) in the collagent type VII alpha 1 chaing (COL7A1) 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.TBDMedical
LantidraDonislecelTBDInfusion into the hepatic portal veinTreatment of adults with Type 1 diabetes who are unable to approach target HbA1c because of current repeated episodes of severe hypoglycemia despite intensive diabetes management and education.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.TBDMedical