Ryplazim^® to require prior authorization for Medicare Advantage members, starting Jan. 17

For dates of service on or after Jan. 17, 2022, Ryplazim (plasminogen, human-tvmh), HCPCS code J3590, will require prior authorization through the NovoLogix^® online tool.

This requirement applies to Medicare Plus Blue^SM and BCN Advantage^SM members.

When prior authorization is required

We require prior authorization when this drug is administered in any site of care other than inpatient hospital (place of service code 21) and is 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

Submitting prior authorization requests

Submit prior authorization requests for these drugs through NovoLogix. It 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.

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 date.

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