Changes to the prior authorization list for medical benefit drugs for Medicare Advantage members

We're adding and removing prior authorization requirements for Medicare Plus Blue^SM and BCN Advantage^SM members as follows.

Additional drug to require prior authorization

For dates of service on or after Dec. 27, 2021, Susvimo^™ (ranibizumab injection, for ocular implant), HCPCS code J3590, will require prior authorization through the NovoLogix^® online tool.

NovoLogix offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to 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.

We require prior authorization for this drug when it’s administered by a health care professional in a provider office, at the member’s home, in an off-campus or on-campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed 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

Drug that will no longer require prior authorization

For dates of service on or after Dec. 1, 2021, Tegsedi^® (inotersen), HCPCS code J3490, no longer requires prior authorization.

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).

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

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