Updated — Medicare Part B medical specialty drug authorization: Clarification regarding Prolia and Xgeva

This message was updated to show that authorization requests for Xgeva should be submitted using the brand name and not the generic name of the drug.

Part B specialty drugs Prolia® and Xgeva® have the same generic name, denosumab, and HCPCS code, J0897. Both drugs require authorization for Medicare Plus BlueSM PPO and BCN AdvantageSM members.

However, the system through which you request authorization varies as follows:

How to bill

Be sure to enter the following National Drug Code numbers on the claim, along with the HCPCS code J0897, to ensure appropriate and timely reimbursement.

For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for all outpatient sites of care when you bill the medications as a professional service or as an outpatient facility service and you bill as follows:

Important reminder

You can quickly submit authorization requests through the NovoLogix online tool and through AIM Specialty Health.

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website*.

*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 required to let you know we're not responsible for its content.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network