Prior authorization requests for outpatient CAR-T therapy drugs for Medicare Advantage members

For dates of service on or after Jan. 1, 2021, outpatient CAR-T therapy drugs such as Yescarta^®, Kymriah^® and Tecartus^™ will be managed by Blue Cross or BCN under the medical benefit for Medicare Plus Blue^SM PPO and BCN Advantage^SM members. For dates of service prior to Jan. 1, 2021, CAR-T cell therapy is covered under Original Medicare.

You must submit prior authorization requests for outpatient CAR-T therapy drugs before providing the service.

Submit prior authorization requests, including all relevant clinical documentation, using one of these methods:

• Enter the request in the NovoLogix^® online tool. For more information about entering requesting in NovoLogix, see the “NovoLogix” section below.
• Fax the request to the Pharmacy Part B help desk at 1-866-392-6465.

Note: Prior authorization for CAR-T drugs is NOT managed by AIM Specialty Health^®.

If you have questions about this, please message us at MASRX@bcbsm.com.

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient places of service when you bill these medications as a professional service or as an outpatient facility service:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

NovoLogix

For these types of drugs, submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application (PDF) form and fax it to the number on the form.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF).