July 2014

Additional specialty drugs to require prior authorization

Clarification: Specialty drug requires prior authorization starting July 1

In a May 2014 Record article, we listed 13 additional specialty drugs administered by health care practitioners that will require prior authorization in order to be covered under members’ medical benefits, starting July 1, 2014. We inadvertently omitted one drug that should have been on the list.

The drug Gammaked^® (procedure code J1561) will require prior authorization starting July 1, 2014.

Five additional specialty drugs administered by health care practitioners will require prior authorization by BCBSM in order to be covered under members’ medical benefits, starting Oct. 1, 2014.

Ensuring proper utilization and addressing the potential safety issues of these high-cost medications will address concerns that many of our major group customers have expressed.

You can find a list of medications that require prior authorization on web-DENIS:

Click on BCBSM Provider Publications and Resources.
Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
Click on Physician administered medications (on the right-hand side under Frequently used forms).

The criteria for authorization of these medications are included on web-DENIS. We will not consider a request for coverage until we receive a physician-signed medication request form for review or the request is uploaded on the online-based tool called Novologix. Requests will follow BCBSM timeframes for coverage determination.

The following drugs will require prior authorization, effective Oct. 1, 2014:

Drug name	Procedure code
Berinert^®	J0597
Cinryze^®	J0598
Firazyr^®	J1744
Kalbitor^®	J1290
Synagis^®	*90378

We’re removing the requirement of prior authorization on the following drug as of Oct. 1, 2014:

Drug name	Procedure code
Mozobil^®	J2562

Blue Cross Blue Shield of Michigan reserves the right to change this list at any time.

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.