Effective July 1, Khapzory^TM and Fusilev^® will be added the prior authorization program for PPO commercial members.

Effective July 1, 2019, Khapzory^TM and Fusilev^® will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan PPO commercial members. This applies to any members starting therapy on or after July 1.

• Fusilev (levoleucovorin calcium, HCPCS code J0641)
• Khapzory (levoleucovorin sodium, HCPCS code J3490)

These drugs are currently included in the prior authorization program for Blue Care Network HMO^SM commercial members.

The authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members.

A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

For a list of requirements related to drugs covered under the medical benefit, do the following:

1. Visit the Medical Benefit Drugs - Pharmacy page in the Blue Cross section at on this website.
2. Click Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO under the heading For Blue Cross (commercial) members.

The new prior authorization requirement for Khapzory and Fusilev will be reflected in the requirements list before the July 1 effective date.

Posted: March 2019
Line of business: Blue Cross Blue Shield of Michigan