Medical Benefit Drugs

Some drugs require prior authorization before they can be delivered or administered in a health care provider's office, clinic, outpatient or home setting. This page offers resources for providers who request prior authorization for provider-administered (infusible/injectable) drugs billed under the medical benefit for Blue Cross commercial and Medicare Plus BlueSM members.

The process of requesting prior authorization for medical benefit drugs differs according to the member's coverage and the type of drug:

  • For Blue Cross commercial members:
    • For most medical benefit drugs, submit prior authorization requests through the NovoLogix® web tool. This includes requests for gene and cellular therapy drugs, such as CAR-T.

      Note: For Blue Cross and Blue Shield Federal Employee Program® non-Medicare members, you can submit requests through NovoLogix or by fax. For information about faxing prior authorization requests, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

    • For medical oncology and supportive care drugs:
  • For Medicare Plus Blue members:
    • For most medical benefit drugs, submit prior authorization requests through NovoLogix. This includes requests for gene and cellular therapy drugs, such as CAR-T.
    • For medical oncology and supportive care drugs:
      • Carelon reviews prior authorization requests through Dec. 31, 2024.
      • Starting Jan. 1, 2025, submit prior authorization requests to OncoHealth.

Did you know?

Michigan's prior authorization law* requires health care providers to submit prior authorization requests electronically for commercial members. Alternate submission methods are allowed in the case of temporary technological problems, such as power or internet outages; see the information about submitting prior authorization requests through alternate methods below.

When you submit your medical drug prior authorization requests electronically, there are many benefits:

  • Faster response times on your requests
  • Approvals within minutes (Some requests require more time.)
  • Reduced administrative time
  • Clinical criteria to guide you in submitting the proper information

Below, you'll find information on how to submit a medical drug prior authorization request electronically for Blue Cross commercial and Medicare Plus Blue members. You'll also find other helpful resources.

IMPORTANT! Always verify eligibility and benefits for each member at each visit. A prior authorization approval is not a guarantee of payment.


Blue Cross commercial

For Blue Cross commercial members, select from below:

How to submit requests electronically using NovoLogix

  1. Verify that the member is eligible and has the appropriate benefits.
  2. Determine whether there are prior authorization or site-of-care requirements by reviewing the appropriate drug list:

    Standard commercial medical drug program

    Group-specific medical drug programs

  3. Determine whether there are quantity limits by reviewing the document titled Blue Cross and BCN quantity limits for medical drugs (PDF).
  4. Log in to our provider portal (availity.com*).
  5. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
  6. In the Applications tab, click the NovoLogix Blue Cross Commercial tile.
  7. Select an organization (if appropriate), select a provider and click Submit. to access NovoLogix.

How to submit requests electronically to Carelon

For Blue Cross commercial URMBT members, submit prior authorization requests to Carelon Medical Benefits Management for all dates of service.

For other Blue Cross commercial members who have requirements under the Oncology Value Management program, submit requests for medical oncology and supportive care drugs to Carelon for dates of service before Jan. 1, 2025, as follows.

  1. Verify that the member is eligible and has the appropriate benefits.
  2. Confirm that the drug requires prior authorization through Carelon by reviewing the appropriate drug list:
  3. Log in to our provider portal (availity.com*).
  4. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
  5. In the Applications tab, click the Carelon ProviderPortal tile.
  6. Select an organization (if appropriate), select a provider and click Submit.

For additional information, refer to the Oncology Value Management program through Carelon FAQs for providers (PDF)

How to submit requests electronically to OncoHealth

For dates of service on or after Jan. 1, 2025, submit requests for medical oncology and supportive care drugs to OncoHealth.

You’ll be able to submit requests to OncoHealth starting Jan. 1, 2025.

See the following for additional information:

Note: When prescribing drugs that are on this list for non-oncology diagnoses, don’t submit the prior authorization request to OncoHealth. Instead, fax all clinical documentation to the Pharmacy Clinical Help Desk at 1-877-325-5979.

Other resources

Newsletter articles (PDF)

Lemtrada and Tysabri site-of-care program: FAQ (PDF)

In-network home infusion therapy providers and ambulatory infusion centers (PDF)

Audaire Health™:

Medical Router

Medication authorization request forms for the standard Blue Cross commercial Medical Drug Prior Authorization Program

Blue Cross and Blue Shield FEP medical policies*

  

Medicare Plus Blue

Select specialty medications covered under the Medicare Part B medical benefit require prior authorization for members covered under Blue Cross Medicare Advantage plans, including Medicare Plus Blue.

For Medicare Plus Blue members, select from below:

How to submit requests electronically using NovoLogix

  1. Verify that the member is eligible and has the appropriate benefits.
  2. Confirm that the drug requires prior authorization by reviewing the Medicare Plus Blue and BCN Advantage drug list (PDF).
  3. Log in to our provider portal (availity.com*).
  4. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
  5. In the Applications tab, click the NovoLogix Medicare Plus Blue tile.
  6. Select an organization (if appropriate), select a provider and click Submit to access NovoLogix.

How to submit requests electronically to Carelon

For dates of service before Jan. 1, 2025, submit requests for medical oncology and supportive care drugs to Carelon as follows.

  1. Verify that the member is eligible and has the appropriate benefits.
  2. Confirm that the drug requires prior authorization through Carelon by reviewing the Medicare Plus Blue and BCN Advantage drug list (PDF).

    Note: When prescribing drugs that are on this list for non-oncology diagnoses, don’t submit the prior authorization request to Carelon. Instead, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

  3. Log in to our provider portal (availity.com*).
  4. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
  5. In the Applications tab, click the Carelon ProviderPortal tile.
  6. Select an organization (if appropriate), select a provider and click Submit.

For additional information, refer to the Oncology Value Management program through Carelon: FAQs for providers (PDF).

How to submit requests electronically to OncoHealth

For dates of service on or after Jan. 1, 2025, submit requests for medical oncology and supportive care drugs to OncoHealth.

You’ll be able to submit requests to OncoHealth starting Jan. 1, 2025.

See the following for additional information:

Note: When prescribing drugs that are on this list for non-oncology diagnoses, don’t submit the prior authorization request to OncoHealth. Instead, fax all clinical documentation to the Pharmacy Clinical Help Desk at 1-877-325-5979.

Other resources

Medicare Plus Blue medical drug policies and forms webpage

Authorization of Part B specialty medications: Frequently asked questions for providers

The Record archive

RC Claim Assist tool

RC Claim Assist is a web-based 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 provides an inclusive overview of medical drug products and a calculation tool to identify the correct National Drug Code and CPT codes to bill, along with the correct NDC quantity, unit of measure and HCPCS billable units according to the package information.

See Using the RC Claim Assist tool: Frequently asked questions for providers (PDF) for additional information.

Training resources

To help you learn to use the NovoLogix web tool:

Additional resources

Alternate methods for submitting prior authorization requests

If you’re experiencing temporary technological problems that prevent you from submitting requests electronically, see the Alternate methods for submitting prior authorization requests for medical benefit drugs (PDF).

Need additional assistance?

For additional help, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

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