Medical benefit specialty drug prior authorization list changing in April for most members

Starting in April 2021, we're adding prior authorization requirements for some drugs covered under the medical benefit. Providers must request prior authorization through AIM Specialty Health^®.

April 15 changes

For dates of service on or after April 15, 2021, the following drug will require prior authorization for UAW Retiree Medical Benefits Trust PPO non-Medicare members:

• Kanjinti^™ (trastuzumab-anns), HCPCS code Q5117

April 22 changes

For dates of service on or after April 22, 2021, the following drugs will require prior authorization for members covered through Blue Cross commercial fully insured members and for BCN commercial, Medicare Plus Blue^SM and BCN Advantage^SM members:

• Danyelza^® (naxitamab-gqgk), HCPCS codes J3490, J3590, J9999, C9399
• Margenza^™ (margetuximab-cmkb), HCPCS codes J3490, J3590, J9999, C9399

These requirements don't apply to:

• Blue Cross and Blue Shield Federal Employee Program^® members
• Michigan Education Special Services Association members

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

• Through the AIM provider portal*
• By calling the AIM Contact Center at 1-844-377-1278

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

More about the authorization requirements

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see:

• Blue Cross commercial fully insured and BCN commercial: Blue Cross and BCN utilization management medical drug list (PDF) and the Medical Oncology Program (PDF) list
• UAW Retiree Medical Benefits Trust non-Medicare members: Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF)

We'll update these lists to reflect these changes prior to the effective dates.

*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.

Posted: January 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network