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September 2019

Quarterly update: Requirements changed for some commercial medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain a comprehensive list of requirements for both PPO and HMO commercial members.

During April, May and June of 2019, the following medical drugs had authorization requirements updates, site-of-care updates or both:

HCPCS code Brand name Generic name
J1599 Asceniv™ Immune globulin
J0584 Crysvita® Burosumab-twza
J1599 Cutaquig® Immune globulin
J3590 Evenity® Romosozumab-aqqp
J0517 Fasenra™ Benralizumab
J3245 Ilumya™ Tildrakizumab-asmn
Q5103 Inflectra® Infliximab-dyyb
J3397 Mepsevii™ Vestronidase alfa-vjbk
J1301 Radicava® Edaravone
J1745 Remicade® Infliximab
Q5104 Renflexis® Infliximab-abda
J3490** Spravato™ Esketamine
J1746 Trogarzo™ Ibalizumab-uiyk
J3590** Ultomiris™ Ravulizumab
J3490**/J3590** Zolgensma® Onasemnogene abeparvovec-xioi

**Will become a unique code.

For a more detailed list of requirements, review the Blue Cross or BCN Drugs Covered Under the Medical Benefit pages at ereferrals.bcbsm.com.

Additional notes
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. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. Follow these steps to access the list:

  1. Log in to Provider Secured Services.
  2. Click on BCBSM Provider Publications and Resources.
  3. Click on Newsletters & Resources.
  4. Click on Forms.
  5. Click on Physician administered medications on the right.
  6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

These changes don’t apply to Medicare Plus BlueSM PPO, Federal Employee Program® Service Benefit Plan or BCN AdvantageSM members.

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for 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 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.