Medicare Part B medical specialty drug prior authorization list changing

We’re making changes to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM and BCN Advantage^SM members. The specialty medications on this list are administered by a health care professional in a provider’s office, at the member’s home, in an off-campus outpatient hospital or in an ambulatory surgical center (place of service 11, 12, 19, 22 or 24).

New authorization requirements

For dates of service on or after July 9, 2020, the following medication for wet age-related macular degeneration will require authorization through the NovoLogix^® online tool:

• Abicipar pegol, HCPCS code J3590

For dates of service on or after Aug. 21, 2020, the following medications will require authorization through NovoLogix:

• Roctavian™ (valoctocogene roxaparvovec), a gene therapy for hemophilia A, HCPCS code J3590
• Uplizna™ (inebilizumab-cdon), HCPCS code J3590
• Avsola™ (infliximab-axxq), HCPCS code Q5121
  
  Note: We published earlier communications stating that Avsola doesn’t require prior authorization. However, for dates of service on or after Aug. 21, 2020, Avsola will require prior authorization.

For dates of service on or after Sept. 28, 2020, the following medications will require prior authorization through NovoLogix:

• Ilaris^® (canakinumab), HCPCS code J0638
• Cutaquig^® (immune globulin subcutaneous [human] – hipp), HCPCS code J1599
• Xembify^® (immune globulin subcutaneous [human] – klhw), HCPCS code J1558

Authorization requirement removed
For dates of service on or after Aug. 1, 2020, the following medications for osteoporosis and other diagnoses involving bone health will no longer require authorization:

• Boniva^® (ibandronate), HCPCS code J1740
• Aredia^® (pamidronate), HCPCS code J2430

How to bill
For Medicare Plus Blue and BCN Advantage, we require authorization for the places of service referenced above when you bill these medications as follows:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form, or
• Electronically through an 837I transaction or by using the UB-04 claim form for a hospital outpatient type of bill 013x

Reminder
Submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements
For a list of requirements for drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.