September 2019

We’re adding medical benefit specialty drugs to prior authorization and site of care programs for PPO members, starting Oct. 1

The Medical Drug Prior Authorization and Site of Care programs are expanding for Blue Cross Blue Shield of Michigan commercial members to include:

HCPCS code	Brand name	Generic name	Prior authorization program	Site of care program
J0202	Lemtrada^®	Alemtuzumab	Yes	No
J2350	Ocrevus^®	Ocrelizumab	Yes	Yes
J2323	Tysabri^®	Natalizumab	Yes	No

Ocrevus (prior authorization and site of care)
We’ll require prior authorization for Ocrevus for members initiating therapy on or after Oct. 1, 2019. If your patient currently receives Ocrevus infusions at an outpatient hospital facility, you may need to discuss other infusion options. Members who currently receive Ocrevus at one of the following locations will be covered until Sept. 30, 2020:

Doctor’s or other health care provider’s office
The member’s home, from a home infusion therapy provider
Ambulatory infusion center

Starting Oct. 1, 2020, these members will need an approval from Blue Cross before we’ll approve payment for Ocrevus.

Lemtrada and Tysabri (prior authorization only)

We’ll require prior authorization for Lemtrada and Tysabri for members initiating therapy on or after Oct. 1, 2019.

Members currently receiving therapy will be covered until Sept. 30, 2020, when received in the following locations:

Doctor’s or other health care provider’s office
The member’s home (from a home infusion therapy provider)
Ambulatory infusion center
Hospital outpatient facility

Starting Oct. 1, 2020, these members will need an approval from Blue Cross before we’ll approve payment for Lemtrada or Tysabri.

More about the authorization requirements

The prior authorization requirements apply only to groups 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. To access the list, log in to Provider Secured Services and follow these steps:

Click on BCBSM Provider Publications and Resources.
Click on Newsletters & Resources.
Click on Forms.
Click on Physician administered medications.
Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

These changes don’t apply to Medicare Plus Blue^SM PPO or Federal Employee Program^® Service Benefit Plan members.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, click here or visit this page on our ereferrals.bcbsm.com website.

The requirements that take effect on Oct. 1 will be reflected in the requirements list by that date.

Blue Cross reserves the right to review drugs for medical necessity before the effective dates listed in this message. We hope you’ll join our effort to keep health care affordable for all by supporting our members as they move to new infusion therapy locations.

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.