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 physician-administered (infusible/injectable) drugs billed under the medical benefit for Blue Care Network commercial and BCN AdvantageSM members.

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

  • For BCN 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.

    • For medical oncology and supportive care drugs, 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).
  • For BCN Advantage 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 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 BCN commercial and BCN Advantage 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.


BCN commercial

For BCN commercial members, select from below:

How to submit requests electronically using the Medical and Pharmacy Drug PA Portal

  1. Verify that the member is eligible and has the appropriate benefits.
  2. Determine whether there are authorization or site-of-care requirements by reviewing the Blue Cross and BCN utilization management medical drug list (PDF).

    3. For Lemtrada® and Tysabri®, see the drug list for additional information related to the site-of-care requirements.

  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 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 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: FAQ 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

 

BCN Advantage

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 BCN Advantage 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 BCN/BCN Advantage 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).

    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.

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

BCN Advantage HMO-POS and BCN Advantage medical drug policies and forms webpage

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

BCN Provider News 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 BCN 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:

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.

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.