Additional medical benefit specialty drugs require prior authorization for Blue Cross' PPO and BCN HMOSM members
This message, originally published on May 31, 2019, is republished on June 3, 2019, to include information about Zolgensma®.
The prior authorization program for specialty drugs covered under the medical benefit is expanding for BCN and Blue Cross commercial members:
For BCN HMO members:
For Blue Cross' PPO members:
More about the authorization requirements
The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to BCN AdvantageSM, Medicare Plus BlueSM PPO or Federal Employee Program® members.
A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.
List of requirements
For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on this website:
The new prior authorization requirements that took effect on June 1 are included in the requirements list. The requirements that take effect on Aug. 1 will be reflected in the requirements list before that date. Blue Cross Blue Shield of Michigan and Blue Care Network reserve the right to review for medical necessity prior to the effective dates listed in this message.
Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network