Medical Benefit Drugs

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

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 CAR-T cell therapy drugs.

      Note: For Blue Cross and Blue Shield Federal Employee Program® non-Medicare members, you can submit requests through NovoLogix or by fax for dates of service on or after Dec. 1, 2020. 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, Carelon Medical Benefits Management (formerly AIM Specialty Health®) manages the prior authorization process. Submit authorization requests through the Carelon ProviderPortal.
      • For Blue Cross commercial fully insured members, for dates of service on or after Dec. 1, 2020. This includes MESSA members for dates of service on or after Jan. 1, 2022.
      • For select Blue Cross commercial self-funded groups, including UAW Retiree Medical Benefits Trust. To determine which groups have opted in and the date on which they opted in, see the Carelon medical oncology prior authorization program opt-in list for Blue Cross commercial self-funded groups (PDF).

        Note: Medical oncology and supportive care drugs don't require authorization through Carelon for members covered through the Blue Cross and Blue Shield Federal Employee Program®.

  • For Medicare Plus Blue members:
    • For most medical benefit drugs, submit prior authorization requests through NovoLogix. This includes requests for CAR-T cell therapy drugs.
    • For medical oncology and supportive care drugs, submit prior authorization requests to Carelon.

Did you know?

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 (formerly AIM)

  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:

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 (formerly AIM)

Starting Jan. 1, 2020:

  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:

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.

To access RC Claim Assist:

  1. Log in to our provider portal (availity.com*).
  2. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
  3. In the Applications tab, click the “RC Claim Assist medical drug coding tool” tile and follow the prompts.

IMPORTANT! The RC Claim Assist drug pricing information is not based on the Blue Cross or BCN administration fee schedule.

For all claims and billing questions, contact PARS / Provider Inquiry at these numbers:

  • Physicians and professionals: 1-800-344-8525
  • Hospitals or facilities: 1-800-249-5103

Training resources

To help you learn to use the NovoLogix web tool:

  • NovoLogix training video on requesting prior authorizations:
    1. Click to open the video*.
    2. Click the arrow located in the center of the "Provider Authorization Video Tutorial" box, to start the video.
  • NovoLogix user guide for Blue Cross providers (PDF)
  • Billing instructions: Reporting the NDC (PDF)
  • Web-based training about NDC billing - Go to our dedicated provider training site*, search on “NDC” and click “National Drug Code billing for medical drug benefits” to start the course.

    Note: To register for the provider training site, click here*. We recommend using the same email you use to communicate with Blue Cross for provider-related needs. This will become your user ID.

Additional resources

Need additional assistance?

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

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.