Medicare Part B medical specialty drug prior authorization list is changing Aug. 21 and Sept. 28

We're adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members. The specialty medications on this list are administered by a healthcare professional in a provider office, at the member's home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

For dates of service on or after Aug. 21, 2020, the following medications will require authorization through the NovoLogix^® online tool:

• A gene therapy for hemophilia A
  • Roctavian^™ (valoctocogene roxaparvovec, HCPCS code J3590)
• Other medications
  • Uplizna^™ (inebilizumab-cdon, HCPCS code J3590)
  • Avsola^™ (infliximab-axxq, HCPCS code Q5121)*

For dates of service on or after Sept. 28, 2020, the following medications will require prior authorization through NovoLogix:

• Ilaris^® (canakinumab, HCPCS code J0638)
• Cutaquig^® (immune globulin subcutaneous (human) - hipp, HCPCS code J1599)
• Xembify^® (immune globulin subcutaneous (human) - klhw, HCPCS code J1558)

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for the sites of care referenced above when you bill these medications as follows:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

For these drugs, submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application (PDF) form and fax it to the number on the form.  

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF).

*Note: On March 16, 2020, we published a web-DENIS message and a news items on the ereferrals.bcbsm.com website stating that Avsola doesn't require authorization. However, for dates of service on or after Aug. 21, 2020, Avsola will require authorization.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network