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, AIM Specialty Health® manages the prior authorization process.
      • For UAW Retiree Medical Benefits Trust PPO non-Medicare members, submit prior authorization requests for medical oncology and supportive care drugs through the AIM ProviderPortal for dates of service on or after Jan. 1, 2019.
      • For Blue Cross commercial fully insured members, submit prior authorization requests to AIM for medical oncology and supportive care drugs for dates of service on or after Dec. 1, 2020.

        Note: Medical oncology and supportive care drugs don't require authorization through AIM for Blue Cross commercial fully insured members covered through the Federal Employee Program and the Michigan Education Special Services Association.

  • 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, AIM Specialty Health® manages the prior authorization process effective Jan. 1, 2020.

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. Log in to Provider Secured Services with your user ID and password.
  4. Click Blue Cross Medical Benefit - Medication Prior Authorization on the Provider Secured Services welcome page to access the NovoLogix tool.
  5. Select the provider's individual NPI and click Go to access NovoLogix.

How to submit requests electronically to AIM

  1. Verify that the member is eligible and has the appropriate benefits.
  2. Confirm that the drug requires prior authorization through AIM by reviewing the appropriate drug list:
  3. Access the AIM provider portal.

For additional information, refer to:

Other resources

Newsletter articles (PDF)

Reviewing e-referral results: Medical drug authorization requests

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

Group opt in/opt out list (PDF)

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 BCN Advantage.

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 drug list (PDF).
  3. Log in to Provider Secured Services with your user ID and password.
  4. Click Medicare Advantage PPO Medical Benefit - Medication Prior Authorization on the Provider Secured Services welcome page to access the NovoLogix tool.
  5. Select the provider's individual NPI and click Go to access NovoLogix.

How to submit requests electronically to 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 AIM by reviewing the Medicare Plus Blue drug list (PDF).
  3. Access the AIM provider portal.

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, log in to bcbsm.com as a provider, click the RC Claim Assist link in the Provider Secured Services welcome page 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:

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.