Medicare Part B medical specialty drug prior authorization lists changing in 2019
Some updates are coming for the Part B medical specialty medical prior authorization drug list for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members. These changes include additions and removals from the prior authorization program as follows.
Medicare Plus Blue PPO
- J0202 Lemtrada®
- J2323 Tysabri®
- J2350 Ocrevus®
- J2840 Kanuma®
- J2860 Sylvant®
- J3357 Stelara® SQ
- J3358 Stelara® IV
- J3490/C9036 OnpattroTM
- J1746 TrogarzoTM
- J9022 Tecentriq®
- J9023 Bavencio®
- J9042 Adcetris®
- J9176 Empliciti®
- J9308 Cyramza®
- J9352 Yondelis®
Removals — for dates of service starting Jan. 1, 2019:
Additions — for dates of service starting Feb. 1, 2019:
For Medicare Plus Blue, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form or by electronic submission via an 837P transaction, for the following sites of care:
- Physician office (Place of Service Code 11)
- Outpatient facility (Place of Service Code 19, 22 or 24)
We do not require authorization for these medications when you bill them on a facility claim form (such as a UB04) or electronically via an 837I transaction.
BCN Advantage
- J9032 Beleodaq®
- J9310 Rituxan®
- J2860 Sylvant®
- J3357 Stelara® SQ
- J3358 Stelara® IV
- J3490/C9036 OnpattroTM
- J1746 TrogarzoTM
- J9022 Tecentriq®
- J9023 Bavencio®
- J9042 Adcetris®
- J9176 Empliciti®
- J9352 Yondelis®
Removals — for dates of service starting Jan. 1, 2019:
Additions — for dates of service starting Feb. 1, 2019:
For BCN Advantage, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form (or submit them electronically via an 837P transaction) or on a facility claim form such as a UB04 (or submit them electronically via an 837I transaction), for the following sites of care:
- Physician office (Place of Service Code 11)
- Outpatient facility (Place of Service Code 19, 22 or 24)
- Home (Place of Service Code 12)
Important reminder
You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests.
Posted: November 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network