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November 2018
Commercial Medical Drug Prior Authorization Program adding Onpattro
Beginning Dec. 1, 2018, Onpattro™ will be added to the Blue Cross Blue Shield of Michigan commercial Medical Drug Prior Authorization Program.
Drug name |
HCPCS code |
Onpattro™ (patisiran) |
J3490 |
The list below shows all medications currently in the Medical Drug Prior Authorization Program.
Drug name |
HCPCS code |
Drug name |
HCPCS code |
Drug name |
HCPCS code |
Actemraz® |
J3262 |
Gammagard® |
J1569 |
Privigen® |
J1459 |
Acthar® gel |
J0800 |
Gammaked® |
J1561 |
Probuphine® |
J3490 / J3590 |
Adagen® |
J2504 |
Gammaplex® |
J1557 |
Prolastin®-C |
J0256 |
Aldurazyme® |
J1931 |
Gamunex® |
J1561 |
Prolia® |
J0897 |
Aralast NP™ |
J0256 |
Glassia™ |
J0257 |
Radicava™ |
J3490 / J3590 |
Aveed® |
J3145 |
Hizentra® |
J1559 |
Remicade® |
J1745 |
Benlysta® |
J0490 |
HyQvia® |
J1575 |
Renflexis™ |
Q5104 |
Berinert® |
J0597 |
Ilaris® |
J0638 |
Ruconest® |
J0596 |
Bivigam™ |
J1556 |
Ilumya® |
J3590 |
Signifor®LAR |
J2502 |
Botox® |
J0585 |
Immune globulin NOS |
J1599 |
Simponi Aria® |
J1602 |
Brineura™ |
J3490 / J3590 |
Inflectra™ |
Q5103 |
Soliris® |
J1300 |
Carimune® NF |
J1566 |
Kalbitor® |
J1290 |
Spinraza™ |
J2326 |
Cerezyme® |
J1786 |
Kanuma™ |
J2840 |
Stelara® |
J3357 |
Cimzia® |
J0717 |
Krystexxa® |
J2509 |
Stelara IV® |
J3358 |
Cinqair® |
J2786 |
Kymriah™ |
Q2040 |
Synagis® |
90378 |
Cinryze® |
J0598 |
Lucentis® |
J2778 |
Testopel® |
S0189 |
Crysvita® |
J3490 / J3590 |
Lumizyme® |
J0221 |
Trogarzo™ |
J3590 |
Cuvitru® |
J1599 |
Luxturna™ |
J3490 / J3590 |
Vimizim™ |
J1322 |
Dysport® |
J0586 |
Makena® |
J1725 |
Vpriv® |
J3385 |
Elaprase® |
J1743 |
Mepsevii™ |
J3490 / J3590 |
Xeomin® |
J0588 |
Elelyso™ |
J3060 |
Myobloc® |
J0587 |
Xgeva® |
J0897 |
Entyvio™ |
J3380 |
Myozyme® |
J0220 |
Xiaflex® |
J0775 |
Exondys 51™ |
J1428 |
Naglazyme® |
J1458 |
Xolair® |
J2357 |
Fabrazyme® |
J0180 |
Nplate® |
J2796 |
Yescarta™ |
Q2041 |
Fasenra™ |
J3490 / J3590 |
Nucala® |
J2182 |
Zemaira® |
J0256 |
Firazyr® |
J1744 |
Octagam® |
J1568 |
Zilretta® |
Q9993 |
Flebogamma® DIF |
J1572 |
Orencia® |
J0129 |
Zinplava™ |
J0565 |
Keep in mind that prior authorization is a clinical review approval only — not a guarantee of payment.
Our office accepts medical drug prior authorization requests by one of the following methods:
Fax |
Mail |
Phone |
1-877-325-5979 |
Blue Cross Blue Shield of Michigan Specialty Pharmacy Program
P.O. Box 2320
Detroit, MI 48231-2320 |
1-800-437-3803 |
You can find prior authorization forms for all physician-administered medications on web-DENIS. When logged in, follow these steps:
- Click on BCBSM Provider Publications and Resources.
- Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
- Click on Under Other Resources, then select Forms.
- Click on Physician administered medications.
Our standard processing time to review requests is 15 days. We’ll review urgent requests within 72 hours.
Note: The prior authorization requirement doesn’t apply to Federal Employee Program® members.
Blue Cross reserves the right to change the prior authorization list at any time.
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