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February 2019

Commercial Medical Drug Prior Authorization Program adds Hemlibra

Beginning March 1, 2019, Hemlibra® will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan commercial PPO members. This change applies to members starting therapy on or after March 1.

Drug name

HCPCS code

Hemlibra® (emicizumab-kxwh)

J7170

Click here to see a list of all medications that require medical drug prior authorization as of March 1, 2019. Keep in mind that prior authorization provides clinical review approval only; it’s not a guarantee of payment.

You can request medical drug prior authorization by using one of the following methods:

Electronic: Provider Secured Services — NovoLogix tool
Fax: 1-877-325-5979
Phone: 1-800-437-3803
Mail: BCBSM Specialty Pharmacy Program
P.O. Box 312320
Detroit, MI 48231-2320

You can find prior authorization forms for physician-administered medications on web-DENIS. When logged in, follow these steps:

  1. Click on BCBSM Provider Publications and Resources.
  2. Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
  3. Under Other Resources,click on Forms.
  4. Click on Physician administered medications.

Refer to the opt-out list for Blue Cross PPO groups that don’t require members to participate in the Commercial Medical Drug Prior Authorization Program. To access the list, follow these steps:

  1. When logged in to web-DENIS, click on BCBSM Provider Publications and Resources. 
  2. Click on Newsletters & Resources.
  3. Click on Forms.
  4. Click on Physician administered medications.
  5. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

Note: The prior authorization requirement doesn’t apply to Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.

Blue Cross reserves the right to make changes to the medical drug prior authorization list at any time.

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 2018 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.