Clarification: Prolia and Xgeva drug authorization

The Part B specialty drugs Prolia^® and Xgeva^® require authorization for Medicare Plus Blue^SM PPO and BCN Advantage^SM members. These drugs have specific instructions for authorization because they have the same generic name, denosumab, and the same HCPCS code, J0897.

Authorization systems are unique for each drug:

• If you’re administering Prolia, used to treat osteoporosis, request the authorization through the NovoLogix^® online tool.
• If you’re administering Xgeva, primarily used to treat bone metastases due to solid tumors, request authorization through the AIM ProviderPortal^SM.

Note: Be sure to use the brand name when requesting Xgeva through the AIM ProviderPortal to ensure AIM knows which medication you’re ordering. Using the generic name, denosumab, can cause delays in the prior authorization process.

How to bill
To ensure appropriate and timely reimbursement, enter the following National Drug Code numbers and HCPCS code on the claim:

• Prolia — Enter NDC 55513071001 and HCPCS code J0897
• Xgeva — Enter NDC 55513073001 and HCPCS code J0897

We require authorization for these medications for all outpatient sites of care. When you bill the medications as a professional service or as an outpatient facility service for Medicare Plus Blue and BCN Advantage, bill one of the following ways:

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

NovoLogix authorization requests
You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:

• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P” to request access to NovoLogix and fax it to the number provided on the form.
• For 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 and fax it to the number provided on the form.

AIM authorization requests
You can submit authorizations through the AIM ProviderPortal or by calling 1-844-377-1278. For information about accessing the AIM ProviderPortal, see the Frequently Asked Questions page on the AIM website.**

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.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.