Leqvio®, Tezspire™ and Vabysmo™ to require prior authorization for commercial members starting in February
We're adding prior authorization requirements for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under the medical benefit:
- For dates of service on or after Feb. 17, 2022:
- Leqvio (inclisiran), HCPCS code J3490
- Tezspire (tezepelumab-ekko), HCPCS code J3490
- For dates of service on or after Feb. 24, 2022: Vabysmo (faricimab-svoa), HCPCS code J3590
Some Blue Cross commercial groups not subject to these requirements
For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list (PDF).
Note: Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.
When submitting requests on or after the effective date for the change
Starting Feb. 17 or Feb. 24, 2022 (as applicable), submit prior authorization requests through the NovoLogix® online tool.
To learn how to submit requests through NovoLogix, visit ereferrals.bcbsm.com and do the following:
- For Blue Cross commercial members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross commercial column, see the “How to submit requests electronically using NovoLogix” section.
- For BCN commercial members: Click BCN and then click Medical Benefit Drugs. In the BCN commercial column, see the “How to submit requests electronically using NovoLogix” section.
When submitting requests before the effective date for the change
Prior to Feb. 17 or Feb. 24, 2022 (as applicable), fax your request for preservice review as follows:
- For Blue Cross commercial members: Fax to Provider Inquiry at 1-866-311-9603.
- For BCN commercial members: Fax to the Medical Drug Help Desk at 1 877 325 5979.
List of requirements
For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members (PDF).
We'll update the list to reflect the changes related to these drugs prior to the effective dates.
Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.
Posted: February 2022
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network