Two additional medical benefit drugs require authorization for BCN effective April 1, 2018

For dates of service on or after April 1, 2018, authorization is required for the two medical benefit drugs shown in the table below, for BCN HMOSM (commercial) members only.

Drug name Procedure code Additional information
MakenaTM J1726 Applies only to BCN HMO (commercial) members who start this drug on or after April 1, 2018
Tysabri® J2323 Applies to BCN HMO (commercial) members who start this drug on or after April 1, 2018, and those who currently take this drug

Providers must submit an authorization request through the NovoLogix electronic system to demonstrate medical necessity. Authorization requests for these drugs should be submitted prior to the start of services.

Medical necessity criteria for these drugs include but are not limited to diagnosis, lab results, dose and frequency of administration. Documentation may also be required that shows the medications previously used to treat the member's condition, including the dose, regimens, dates of therapy and response. Additional pertinent clinical information may also be required.

These new authorization requirements do not apply to BCN AdvantageSM members.

For a full list of drugs that require authorization and for information on how to request authorization, visit the Medical Benefit Drugs–Pharmacy page in the BCN section of this website.


Posted: February 2018
Line of business: Blue Care Network