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 Blue Shield of Michigan 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 Medical and Pharmacy Drug PA Portal, which you can access by clicking the Medical/Pharm Drug Benefit Prior Auth (Commercial) tile in in our provider portal (availity.com*). This includes requests for gene and cellular therapy drugs.

      Note: For Blue Cross and Blue Shield Federal Employee Program® non-Medicare members, you can submit requests through the Medical and Pharmacy Drug PA Portal 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 Blue Cross commercial UAW Retiree Medical Benefits Trust members, submit prior authorization requests to Carelon Medical Benefits Management.
      • For most other Blue Cross commercial members, submit prior authorization requests to OncoHealth. To determine which self-funded groups have requirements under the program, see the Oncology Value Management program participation list for commercial self-funded groups (PDF).

        Note: Medical oncology and supportive care drugs don't require prior authorization through Carelon or OncoHealth for MESSA members or 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 gene and cellular therapy drugs.
    • For medical oncology and supportive care drugs, 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 technical 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 prior authorization requests electronically through the Medical and Pharmacy Drug PA Portal

  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 Medical/Pharm Drug Benefit Prior Auth (Commercial) tile.

How to submit requests electronically to Carelon for Blue Cross commercial URMBT members

For Blue Cross commercial URMBT members, submit prior authorization requests to Carelon Medical Benefits Management as follows.

Note: 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 OncoHealth.

  1. Verify that the member is eligible and has the appropriate benefits.
  2. Determine whether the drug requires prior authorization through Carelon by reviewing the Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members: Medications that require authorization by Carelon (PDF)

    3. Note: When prescribing these drugs for non-oncology diagnoses, don't submit the prior authorization request to Carelon. Instead, fax all clinical documentation to the Pharmacy Clinical Help Desk at 1-877-325-5979.

  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 Provider Portal 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 most members

Submit requests for medical oncology and supportive care drugs to OncoHealth as follows.

Note: For Blue Cross commercial URMBT members, submit prior authorization requests to Carelon.

  1. Verify that the member is eligible and has the appropriate benefits.
  2. Determine whether the drug requires prior authorization through OncoHealth by reviewing the Medical oncology prior authorization list for Blue Cross and BCN commercial members (PDF)

    3. To determine which commercial self-funded groups have requirements under the program, see the Oncology Value Management program participation list for commercial self-funded groups (PDF).

    Note: When prescribing these drugs 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.

  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 OncoHealth Provider Portal tile.
  6. Select an organization (if appropriate), select a provider and click Submit.

For additional information, see the Oncology Value Management program through OncoHealth: FAQs for providers (PDF).

If you have questions about the Oncology Value Management program, call OncoHealth at 1-888-916-2616.

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 Policy Router

Changes to medical necessity criteria for prior authorizations for medical benefit drugs (PDF)

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 OncoHealth

Submit requests for medical oncology and supportive care drugs to OncoHealth as follows:

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

    3. Note: When prescribing drugs that are on this list for non-oncology diagnoses, don't submit the prior authorization request to OncoHealth. 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 OncoHealth Provider Portal tile.
  6. Select an organization (if appropriate), select a provider and click Submit to access NovoLogix.

For additional information, see the Oncology Value Management program through OncoHealth: FAQ for providers (PDF).

If you have questions about the Oncology Value Management program, call OncoHealth at 1-888-916-2616.

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 how to use the Medical and Pharmacy Drug PA Portal for Blue Cross commercial members, view a recorded demo by going to Blue Cross and BCN’s Provider Training site, searching on drugs and launching the “Medical and Pharmacy Drug PA Portal Overview.”

(For detailed information about accessing the Provider Training site, see the “Online training” section of the Training Tools page on ereferrals.bcbsm.com.)

To help you learn to use the NovoLogix web tool for Medicare Plus Blue and BCN Advantage members:

  • 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.
  • Billing instructions: Reporting the NDC (PDF)
  • Web-based training about NDC billing:

    We offer provider training. To learn more, see our Training Tools page.

Additional resources

Alternate methods for submitting prior authorization requests

If you're experiencing temporary technical 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.

*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.

Availity® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

NovoLogix® is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

OncoHealth is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing cancer support services.