Drugs Covered Under the Medical Benefit

Submit your medical drug authorization requests online to:

  • Save time
  • Check authorization status
  • Receive immediate approvals for some medications

Click the Login button on the top left of this screen. Then click either:

  • BCBSM Medical Benefit – Medication Prior Authorization, for Blue Cross commercial members (PPO and traditional coverage)
  • Medicare Advantage PPO Medical Benefit – Medication Prior Authorization, for Blue Cross Medicare Plus Blue PPO plans

Checking your results

Our tip sheet (PDF) shows you how to check the results of your Blue Cross commercial PPO request.

When a patient needs a drug under the medical benefit, Blue Cross Blue Shield of Michigan may need to approve it first. Keep in mind that prior authorization is just a clinical review approval, not a guarantee of payment. You'll still need to verify the necessary coverage for this medical benefit.

For Blue Cross commercial members

Providers can go to the Physician administered medications page within our Provider Secured Services website for more information on physician-administered medications for patients with Blue Cross coverage, including:

  • Quantity Limit Program information
  • Quantity Limit Request form
  • Frequently Asked Questions about the Prior Authorization of Medical Drugs
  • Forms for the specific medications

Here's how to find the Physician administered medications page:

  1. Log in as a provider at bcbsm.com.
  2. Click BCBSM Provider Publications and Resources on the lower right side of the page.
  3. Click Newsletters and Resources.
  4. Click the Forms link in the left navigation.
  5. Click Physician administered medications.

Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO (PDF)

Prior Authorizations for medical drugs can be submitted online by accessing BCBSM Medical Benefit-Medication Prior Authorization link on the secure provider portal or by using one of the PA forms found in the Physician administered medications section referenced above.

For Blue Cross Medicare Advantage members

Effective July 5, 2017, select specialty medications covered under the Medicare Part B medical benefit require prior authorization for members covered under Blue Cross Medicare Advantage plans, specifically Blue Cross Blue Shield of Michigan's Medicare Plus BlueSM PPO plans.

Providers may use our NovoLogix® online tool to submit specialty medical drug authorization requests for members covered under Medicare Advantage plans.

Resource documents

RC Claim Assist tool — For Blue Cross commercial & Blue Cross Medicare Advantage

RC Claim Assist, created by RJ Health Systems, is a free resource available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. RC Claim Assist should only be used for claims submitted for Blue Cross or BCN commercial members. The tool provides a comprehensive overview of HCPCS and CPT drug codes, product names and national drug codes. It also offers complete drug information on package-size billable units and reference pricing.

The tool should be used as a general reference only in conjunction with other resources, such as applicable fee schedules. It provides real-time data, reflecting information that's valid as of the day and time you use the tool. The tool doesn't include benefit, payment or medical policy information.

Here are some resources related to RC Claim Assist:

Billing information – for Blue Cross or BCN commercial members only

RC Claim Assist log-in* - tool to help you identify the correct National Drug Code to bill along with the correct NDC billable units and NDC unit of measure

If you have questions about: Do this:
The data you see on RC Claim Assist Send an email to info@rjhealthsystems.com.
Billing or claims Contact Provider Inquiry.
A claim that is contractual or complex in nature Contact your provider consultant.

Billing instructions: Reporting the National Drug Code (PDF)

*Blue Cross does not control this website or endorse its general content.