Blue Cross Medical Benefit Drugs: How to submit requests electronically

The process of requesting prior authorization for medical benefit drugs differs according to the member's coverage and the type of drug:

For Blue Cross commercial members:

For most medical benefit drugs, submit prior authorization requests through the NovoLogix^® web tool. This includes requests for gene and cellular therapy drugs.

Note: For Blue Cross and Blue Shield Federal Employee Program® non-Medicare members, you can submit requests through NovoLogix or by fax. For information about faxing prior authorization requests, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

For medical oncology and supportive care drugs:

For Blue Cross commercial UAW Retiree Medical Benefits Trust members, submit prior authorization requests to Carelon Medical Benefits Management.
For most other Blue Cross commercial members, submit prior authorization requests to OncoHealth. To determine which self-funded groups have requirements under the program, see the Oncology Value Management program participation list for commercial self-funded groups

Note: Medical oncology and supportive care drugs don't require prior authorization through Carelon or OncoHealth for MESSA members or members covered through the Blue Cross and Blue Shield Federal Employee Program^®.

For Medicare Plus Blue^℠ members:

For most medical benefit drugs, submit prior authorization requests through NovoLogix. This includes requests for gene and cellular therapy drugs.
For medical oncology and supportive care drugs, submit prior authorization requests to OncoHealth.

Blue Cross commercial

How to submit requests electronically using NovoLogix

Verify that the member is eligible and has the appropriate benefits.
Determine whether there are authorization or site-of-care requirements by reviewing the appropriate drug list:

Standard commercial medical drug program

Blue Cross and BCN utilization management medical drug list
For Lemtrada^® and Tysabri^®, see the drug list for additional information related to the site-of-care requirements.
To determine which Blue Cross commercial self-funded groups have opted in to the standard commercial drug program, see Group opt in/opt out list

Standard commercial medical drug program

UAW Retiree Medical Benefits Trust non-Medicare members: Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members
FEP non-Medicare members: Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members

Determine whether there are quantity limits by reviewing the document titled Blue Cross and BCN quantity limits for medical drugs .
Log in to our provider portal (availity.com)
Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
In the Applications tab, click the NovoLogix BCN/BCN Advantage tile.
Select an organization (if appropriate), select a provider and click Submit.

How to submit requests electronically to Carelon for Blue Cross commercial URMBT members

For Blue Cross commercial URMBT members, submit prior authorization requests to Carelon Medical Benefits Management as follows.

Note: For other Blue Cross commercial members who have requirements under the Oncology Value Management program, submit requests for medical oncology and supportive care drugs to OncoHealth.

Verify that the member is eligible and has the appropriate benefits.
Determine whether the drug requires prior authorization through Carelon by reviewing the Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members: Medications that require authorization by Carelon

Note: When prescribing these drugs for non-oncology diagnoses, don't submit the prior authorization request to Carelon. Instead, fax all clinical documentation to the Pharmacy Clinical Help Desk at 1-877-325-5979.
Log in to our provider portal (availity.com)
Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
In the Applications tab, click the Carelon Provider Portal tile.
Select an organization (if appropriate), select a provider and click Submit.

For additional information, refer to the Oncology Value Management program through Carelon FAQs for providers

How to submit requests electronically to OncoHealth for most members

Submit requests for medical oncology and supportive care drugs to OncoHealth as follows.

Note: For Blue Cross commercial URMBT members, submit prior authorization requests to Carelon.

Verify that the member is eligible and has the appropriate benefits.
Determine whether the drug requires prior authorization through OncoHealth by reviewing the Medical oncology prior authorization list for Blue Cross and BCN commercial members

To determine which commercial self-funded groups have requirements under the program, see the Oncology Value Management program participation list for commercial self-funded groups.

Note: When prescribing these drugs for non-oncology diagnoses, don't submit the prior authorization request to OncoHealth. Instead, fax all clinical documentation to the Pharmacy Clinical Help Desk at 1-877-325-5979.
Log in to our provider portal (availity.com)
Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
In the Applications tab, click the OncoHealth Provider Portal tile.
Select an organization (if appropriate), select a provider and click Submit.

For additional information, see the Oncology Value Management program through OncoHealth: FAQ for providers

Medicare Plus Blue

Select specialty medications covered under the Medicare Part B medical benefit require prior authorization for members covered under Blue Cross Medicare Advantage plans, including Medicare Plus Blue.

How to submit requests electronically using NovoLogix

Verify that the member is eligible and has the appropriate benefits.
Confirm that the drug requires prior authorization by reviewing the Medicare Plus Blue and BCN Advantage drug list.
Log in to our provider portal (availity.com)
Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
In the Applications tab, click the NovoLogix Medicare Plus Blue tile.
Select an organization (if appropriate), select a provider and click Submit.

How to submit requests electronically to OncoHealth

Submit requests for medical oncology and supportive care drugs to OncoHealth as follows:

Verify that the member is eligible and has the appropriate benefits.
Determine whether the drug requires prior authorization through OncoHealth by reviewing the Medicare Plus Blue and BCN Advantage drug list.

Note: When prescribing drugs that are on this list for non-oncology diagnoses, don't submit the prior authorization request to OncoHealth. Instead, call the Pharmacy Clinical Help Desk at 1-800-437-3803.
Log in to our provider portal (availity.com)
Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
In the Applications tab, click the OncoHealth Provider Portal tile.
Select an organization (if appropriate), select a provider and click Submit.

For additional information, see the Oncology Value Management program through OncoHealth: FAQ for providers

RC Claim Assist tool

RC Claim Assist is a web-based resource available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. RC Claim Assist provides an inclusive overview of medical drug products and a calculation tool to identify the correct National Drug Code and CPT codes to bill, along with the correct NDC quantity, unit of measure and HCPCS billable units according to the package information.

See Using the RC Claim Assist tool: Frequently asked questions for providers for additional information.

Training Resources

To help you learn to use the NovoLogix web tool:

NovoLogix training video on requesting authorizations:

Click to open the video
Click the arrow located in the center of the "Provider Authorization Video Tutorial" box, to start the video.

NovoLogix user guide for BCN providers
NovoLogix user guide for Blue Cross providers
Billing instructions: Reporting the NDC

Web-based training about NDC billing:

We offer provider training. To learn more, see our Training Tools page.

Availity® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

NovoLogix® is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

OncoHealth is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing cancer support services.