Aduhelm^™, Empaveli^™ and Arcalyst^® to require prior authorization for Medicare Advantage members

The following medications will require prior authorization through the NovoLogix^® online tool:

• Aduhelm (aducanumab), HCPCS code J3590 — for dates of service on or after June 8, 2021
• Empaveli (pegcetacoplan), HCPCS codes J3490, J3590 — for dates of service on or after June 14, 2021
• Arcalyst (rilonacept), HCPCS code J2793 — for dates of service on or after Sept. 13, 2021

This applies to Medicare Plus Blue^SM and BCN Advantage^SM members.

When prior authorization is required

For Medicare Advantage members, we require prior authorization for these drugs when they're administered by a health care professional in a provider office, at the member's home, in an off-campus or on-campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

• 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

Important reminder

Submit prior authorization requests for these drugs 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 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).

We'll update the list to reflect these changes.

Posted: June 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network