Prior authorization requests for outpatient CAR-T therapy drugs for Medicare Advantage members

For dates of service on or after Jan. 1, 2021, outpatient CAR-T therapy drugs, such as Yescarta^®, Kymriah^® and Tecartus™, will be managed by Blue Cross Blue Shield of Michigan or Blue Care Network under the medical benefit for Medicare Plus Blue℠ and BCN Advantage℠ members. For dates of service prior to Jan. 1, 2021, CAR-T cell therapy is covered under Original Medicare.

You must submit prior authorization requests for outpatient CAR-T therapy drugs before providing services.

Submit prior authorization requests, including all relevant clinical documentation, using one of these methods:

• Enter the request in the NovoLogix^® online tool. For more information about this process, see the “NovoLogix” section below.
• Fax the request to the Pharmacy Clinical Help Desk at 1-866-392-6465.

Note: Prior authorization for CAR-T drugs isn’t managed by AIM Specialty Health^®.

If you have any questions, send an email to MASRX@bcbsm.com.

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient places of service when you bill these medications as a professional or outpatient facility service as follows:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

NovoLogix

For CAR-T therapy drugs, submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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 related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.