Here’s an update on temporary changes due to COVID-19 pandemic

Blue Cross Blue Shield of Michigan and Blue Care Network have made many temporary changes to support providers and protect members during the COVID-19 pandemic. Some of those changes have ended and one has been extended.

These updates apply to Blue Cross commercial, BCN commercial, Medicare Plus Blue^SM and BCN Advantage^SM members, unless otherwise noted.

To determine end dates for other temporary actions Blue Cross and BCN have taken, see the Temporary changes due to the COVID-19 pandemic document. You can find this document on our public website at bcbsm.com/coronavirus and through Provider Secured Services.

We’ve created billing tips for COVID-19 diagnosis codes

We’ve experienced many changes during the COVID-19 pandemic. To make billing easier for you, we’ve created two reference documents:

• Billing tips for COVID-19 compiles all the changes together into one document.
• Billing tips for COVID-19 at a glance is a one-pager of highlights.

Two diagnosis codes for confirmed COVID-19 for dates of service prior to April 1, 2020, were not included in the chart of diagnosis codes in the May Record article on COVID-19 billing guidelines. Please refer to the Billing tips for COVID-19 for a complete list of diagnosis codes for COVID-19.

The billing tips documents can be found on our Coronavirus (COVID-19) information updates for providers page. Log in as a provider at bcbsm.com and click on Coronavirus (COVID-19). You can also find information at bcbsm.com/coronavirus by clicking on For Providers.

COVID-19 HCPCS and CPT codes added

The Centers for Medicare & Medicaid Services has added a new COVID-19 code as part of its quarterly Health Care Procedure Coding System updates. The code, effective date and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

HCPCS code: Pathology and Laboratory

There is also a new COVID-19-related CPT code as follows:

CPT code: Pathology and Laboratory

Proprietary Laboratory Analysis Code

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Changes to Michigan’s auto no-fault insurance law may increase need for coordination of benefits

Effective with auto insurance policies issued or renewed after July 1, 2020, individuals will no longer be required to carry unlimited personal injury protection, or PIP, with their auto insurance. Under certain circumstances, drivers can select different levels — or opt out — of PIP coverage through their auto insurer.

In situations where a member’s auto insurance is considered primary to their Blue Cross Blue Shield of Michigan coverage — and they select a level of PIP coverage that’s less than unlimited — their auto insurance benefits may run out. These changes to Michigan’s auto no-fault insurance law may lead to more instances where providers need to coordinate benefits for their patients.

More of what you need to know

• Continue to bill auto accidents as you do today.
• Enter the appropriate value indicating an auto-accident claim.
• Continue to follow existing Medicare guidelines pertaining to billing and secondary payer rules.
• PIP is a “lifetime per accident per patient” benefit, not an “annual per family or per individual” maximum.
• PIP coverage pays for some items that health insurance doesn’t, such as attendant care, lost wages and vehicle or housing modifications. (PIP also pays for services that Medicare coverage may not, such as transportation to and from medical appointments and vehicle modifications.)
• If the auto insurer is considered the primary payer, Blue Cross will reject the claim if we’re billed as primary payer.
• When the member’s auto PIP benefits are exhausted, you’ll receive a rejection from the auto insurer. (PR*119 or PR*149 may be indicated on the 835 denial.) You can then bill Blue Cross, indicating Blue Cross is secondary.
• When you bill Blue Cross as a secondary payer, you’ll need to include the primary auto insurer name along with the primary auto insurance claim decision resolution (value code) on the 837.

Determining which insurance is primary

Provider should ask members:

• Do you have coverage from more than one insurance carrier?
• Is your injury the result of an accident?
• Does your medical coverage have any restrictions, such as not paying for claims related to an auto accident or paying secondary only?

Note: In most cases, Blue Cross is the primary payer and health care providers will continue to bill Blue Cross first.

If you need more information about how Blue Cross coordinates auto insurance benefits, refer to the Blue Cross PPO (Commercial) Provider Manual by logging in to Provider Secured Services. Refer to the auto insurance section of the Coordination of Benefits chapter.

If you have questions about coordinating benefits with a member’s existing auto insurer, call Provider Inquiry. Professional providers can call Provider Inquiry at 1-800-344-8525 and hospital and other facility providers can call 1-800-249-5103.

Blue Cross recognized by J.D. Power for highest member satisfaction among commercial health plans in Michigan

Putting members first is a hallmark of our work at Blue Cross Blue Shield of Michigan. That’s why we at Blue Cross are honored to receive the J.D. Power Award for highest member satisfaction among commercial health plans in Michigan for the second time in three years.

We want to thank our health care providers for the role they’ve played in helping us achieve this honor. The experience members have in provider practices and hospitals influences their impression of Blue Cross.

This award is given to the Michigan health plan that ranks first place overall in the J.D. Power 2020 Commercial Member Health Plan study. It recognizes our efforts at Blue Cross to make sure our members are taken care of with the right care at the right time.

Improving the experience for members has been the focus of many Blue Cross initiatives throughout the past few years. Those include:

• Making health care more affordable through Value-Based Contracting and  Blueprint for Affordability
• Working closely with health care providers to improve health care quality through our Physicians Group Incentive Program and Collaborative Quality Initiatives
• Launching programs to support care management and diabetes management
• Improving access to health care through the Blue Cross Online Visits app
• Enhancing our Blue Cross mobile app and bcbsm.com with the new MIBlue Virtual Assistant chat feature, which enables members to get answers to their health plan questions 24/7

We appreciate the care you give to your patients — our members — and your ongoing efforts to improve health care quality and affordability.

Blue Cross Blue Shield of Michigan received the highest score in Michigan in the J.D. Power 2020 U.S. Member Health Plan Study of customers’ satisfaction with their commercial health plan. Visit jdpower.com/awards.

Blue Cross and BCN waiving cost share for Medicare Advantage members

As announced on May 7, Blue Cross Blue Shield of Michigan and Blue Care Network are waiving cost share for their Medicare Advantage individual and fully insured group members for certain in-person and virtual services. Members won’t be liable for any copays, coinsurance or deductibles for the following network services from May 1 through Dec. 31, 2020:

• In-person primary care services, including laboratory testing processed in the office and radiology services performed in the office
• Behavioral health office visits
• Telehealth services for both medical and behavioral health

Some Medicare Advantage groups are still making decisions on this waiver, and we’ll give further guidance as soon as possible for those groups.

During the COVID-19 state of emergency, cost share for these services will also be waived for out-of-network services. Medicare Advantage organizations are required to provide the same cost sharing for the enrollee at a non-contracted facility as if the service or benefit had been furnished at a plan-contracted facility.

The waiving of member cost share will be calculated accurately on the remittance advice but may not be reflected when checking benefits in our systems.

In-person medical services

BCN Advantage^SM members: Cost share is waived for any in-person medical services provided by the member’s primary care provider.

Medicare Plus Blue^SM members: Cost share is waived for all in-person medical services billed with a rendering provider based on the designations below with the following places of service: 03, 11, 12, 13, 14, 15, 19, 22, 34, 49, 50, 71 and 72.

• Certified nurse specialist
• General practice
• Geriatric medicine
• Family nurse practitioner
• Family practice
• Internal medicine
• Obstetrics/gynecology
• Nurse practitioner
• Pediatric medicine
• Pediatric nurse practitioner
• Physician assistant

Member cost share isn’t waived for:

• Services provided by medical specialists other than the provider types listed above
• Services provided in urgent care centers
• Laboratory services ordered by a physician and sent to an outside laboratory provider (other than COVID-19 testing)
• Medicare Part B medications administered in the office
• Supplies received from the physician in the office

In-person behavioral health services

Member cost sharing is waived for Medicare Advantage members seeking behavioral health services in a physician’s office including individual therapy, psychiatric medication consultation and group therapy.

BCN Advantage members: Evaluation and management services are covered at no cost share for the following diagnoses:

• F10-F1999
• F55-F558
• F01-F09
• F20-F54
• F59-F99

Medicare Plus Blue members: Evaluation and management services are covered at no cost share when used with the following specialties:

• Psychiatry
• Clinical psychologist (billing independently)
• Addiction medicine
• Licensed clinical social worker
• Neuropsychiatry
• Adult psychiatric mental health nursing

The following are CPT codes for behavioral health in-person visits covered with no cost share for both Medicare Plus Blue and BCN Advantage members:

Evaluation and management services: *99201-*99205, *99211-*99215

Other: *90791, *90792, *90832, *90833, *90834, *90836, *90837, *90838, *90846, *90847, *90853, *96101, *96102, *96111, *90839, *90840, *90849

Telehealth services

On April 30, the Centers for Medicare & Medicaid Services further expanded the list of services covered through telehealth to allow providers to care for patients and mitigate the risk of spreading the coronavirus. Clinicians can provide these services to new or established patients.

Blue Cross and BCN are waiving cost share for telehealth services for both medical and behavioral health for their Medicare Advantage members effective March 16 through Dec. 31. Medicare Plus Blue and BCN Advantage members can receive telehealth and other communications technology-based services wherever they are located. As mentioned earlier in this article, some self-funded Medicare Advantage groups are still making decisions on this waiver but have waived cost share through at least June 30 for these telehealth services. We’ll give further guidance as soon as possible for those groups.

Refer to our Telehealth procedure codes for COVID-19 document for the list of covered telehealth services for our Medicare Advantage members as well as Blue Cross commercial and BCN commercial members.

We invite you to join PGIP as a physician organization

Our Physician Group Incentive Program offers incentives to participating practitioners, physician organizations and organized systems of care for improving health care delivery. We’re pleased to announce that we’ll accept applications for PGIP from new POs from Aug. 1 through Aug. 31, 2020.

To request application materials, send an email to valuepartnerships@bcbsm.com.

A PGIP physician organization consists of Blue Cross Blue Shield of Michigan TRUST or Traditional network physicians working together to:

• Transform systems of care to effectively manage patient populations.
• Build the infrastructure needed to optimize, measure and monitor quality of care.
• Promote collaborative relationships.
• Support the most cost-effective delivery of services to improve patient outcomes.

About PGIP
PGIP is an innovative provider program developed with input from providers across Michigan to help improve the quality and efficiency of health care in the state. PGIP facilitates change through approximately 20 initiatives, including our nationally recognized Patient-Centered Medical Home program. PGIP rewards physician organizations and organized systems of care for improving health care delivery to their attributed patient population.

If you’re interested in participating in PGIP as an individual practitioner, click here to learn more about PGIP physician organizations.

For more information on PGIP, visit the Physician Group Incentive Program section of valuepartnerships.com.

Vaccine Affiliation Agreement amended

We’re amending our Vaccine Affiliation Program to permit pharmacies participating in the program to submit medical claims to Blue Care Network for services listed on the Medical Immunization Pharmacy Providers Payable Vaccines Fee Schedule, which is updated occasionally.

Our Vaccine Affiliation Agreement remains unchanged for Blue Cross Blue Shield of Michigan members.

A previous amendment to the agreement expanded the program to pharmacies participating with BCN with certain exceptions. One of the exceptions was that covered services for BCN members were limited to adult immunizations only.

The Second Amendment to the Vaccine Affiliation Agreement removes this limitation and now provides that covered services for BCN members include adult immunizations and certain other testing as described in the fee schedule, subject to the other terms and conditions of the agreement.

As background, we announced in The Record in 2016 that Blue Cross members could get select vaccines under the pharmacy benefit starting Oct. 1, 2016.

2020 second-quarter CPT update: New and deleted codes

Pathology and laboratory
Proprietary laboratory analysis codes

Category III
Surgery

Category III
Surgery/Eye and ocular adnexa

Category III
Surgery
Eye and ocular adnexa intraocular lens procedure

Category III codes
Cardiovascular services

Category III
Medicine
Ophthalmology

Category III
Medicine
Ophthalmology special ophthalmological services

Category III
Other medical service

Category III
Surgery digestive

Category III
Diagnostic services
Active wound care Management

Category III
Surgery urinary

Category III
Medicine

Category III
Surgery cardiovascular

Category III
Diagnostic radiology

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

2020 HCPCS update: New code added

The Centers for Medicare & Medicaid Services has added a new code as part of its quarterly Health Care Procedure Coding System updates. The code, effective date and Blue Cross Blue Shield of Michigan’s coverage decision are below.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

Reminder: We’ve postponed some pharmacy initiatives

As you may have read in a web-DENIS message in April, the effective dates for some pharmacy initiatives that we communicated about in The Record have been postponed due to our efforts to combat COVID-19.

The following are links to the original Record articles, published in March and April, containing effective dates that are no longer valid:

• Changes for medications that treat nausea and vomiting
• Changes for Soma products
• Changes for medications that treat migraines

Once the new effective dates for these initiatives have been established, we’ll communicate them through The Record.

New webinar recordings of 2020 sessions now available

Provider Experience continues to offer training resources to help your clinical and administrative staff work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network. We’ve added recordings and videos of the following webinars to the Learning Opportunities section of web-DENIS:

• Blue Cross 201: Claims Appeals Overview
• e-referral Upgrades
• Hyaluronic Acid Knee Injections
• Medical benefit drugs: Prior authorization and claim submission scenarios (E-Learning)
  

To access recordings of the provider training webinars we’ve delivered so far in 2020 through web-DENIS, follow these steps:

For Blue Cross

1. Click on BCBSM Provider Publications and Resources.
2. Click on Newsletters & Resources.
3. Click on Provider Training under Popular Links.
4. Find the webinar you want in the Featured Links section.
5. For Medical benefit drugs, click on E-Learning under Quick Access.

For BCN

1. Click on BCN Provider Publications and Resources.
2. Click on Learning Opportunities under Other Resources.
3. Click on the link you want under 2020 Provider Training Webinars.

As additional training webinars become available, we’ll let you know about them through web-DENIS or The Record.

2020 InterQual^® criteria to be implemented Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2020 InterQual criteria on Aug. 1, 2020, to make utilization management determinations. There is InterQual criteria for behavioral health services, as well as non-behavioral health services. However, for Blue Cross commercial members, New Directions, an independent company that provides behavioral health services for most Blue Cross members, uses its own criteria for making determinations.

Non-behavioral health services
We’ll use updated criteria for all levels of care to make utilization management determinations for requests to authorize non-behavioral health services, subject to review, for the following members:

• Blue Cross commercial
• Medicare Plus Blue^SM
• BCN commercial
• BCN Advantage^SM

When clinical information is requested for a medical or surgical admission or for other services, we require submission of the specific components of the medical record that validate that the request meets the criteria.

Blue Cross and BCN also use local rules — modifications of InterQual criteria — in making utilization management determinations. The 2020 local rules will also go into effect on Aug. 1, 2020.

You’ll be able to access the updated versions of the modifications (local rules), as applicable, for [Note to reviewers – updated criteria will be posted by June 26]:

• Blue Cross — on the Authorization Requirements & Criteria page in the Blue Cross section of our ereferrals.bcbsm.com website. You’ll see links to the criteria in both Blue Cross’ PPO and the Medicare Plus Blue PPO sections of that page. You can also find the 2020 InterQual criteria by the end of July within Provider Secured Services. After you log in, click BCBSM Provider Publications and Resources. Click Newsletters & Resources, click Clinical Criteria & Resources and scroll down to the section titled BCBSM modifications to InterQual criteria.
• BCN — on the Authorization Requirements & Criteria page in the BCN section of our ereferrals.bcbsm.com website. Look under the Referral and authorization information heading.

Refer to the table below for more specific information on which criteria are used in making determinations for various types of non-behavioral health authorization requests.

Note: The information in the table above applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by an independent company that provides services to Blue Cross Blue Shield of Michigan.

Behavioral health services
BCN commercial, BCN Advantage^SM and Medicare Plus Blue^SM will begin using the 2020 InterQual^® criteria for behavioral health utilization management determinations on Aug. 1.

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below.

Links to the updated versions of the modified criteria, local rules and medical policies will be available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com.

As noted earlier in this article, determinations for behavioral health services for Blue Cross commercial members are handled by New Directions, an independent company that provides behavioral health services for most Blue Cross members. New Directions uses its own Medical Necessity Criteria.

Reminder: Providers must submit authorization requests to TurningPoint for musculoskeletal surgical procedures for certain members

As we reported in the May issue  of The Record, you need to submit authorization requests for all surgical procedures related to musculoskeletal conditions to TurningPoint, starting June 1, for dates of service on or after July 1. (The original launch date of June 1 had moved to July 1 due to the COVID-19 pandemic.)

Some important reminders:

• This is effective for BCN commercial, BCN Advantage^SM and Medicare Plus Blue^SM members.
• Facilities should have an authorization number before scheduling surgery. The ordering physician or provider office must secure the authorization and provide the authorization number to the facility.
• For inpatient professional claims, make sure to include only the procedure codes authorized for musculoskeletal procedures on your claim.
• TurningPoint began accepting submitted authorization requests on June 1.

We’ll continue to offer webinar training for providers and facilities. Use the links below to register for webinars:

• Training for professional providers
• Training for facility providers
• Portal training (professional providers only)

Where to find more information
For more information about TurningPoint, see the ereferrals webpages for Blue Care Network and Blue Cross Blue Shield of Michigan.

You can find procedure codes for orthopedic and spinal procedures managed by TurningPoint on ereferrals.bcbsm.com. Here are the links:

• Orthopedic
• Spinal

You can also refer to the Frequently asked questions document on our ereferrals.bcbsm.com website.

Blue Cross, BCN add provider group that addresses OCD, phobias and anxiety disorders by telehealth to network

Blue Cross Blue Shield of Michigan and Blue Care Network recently added a new provider group, called NOCD, that uses telehealth to address obsessive-compulsive disorders, phobias and anxiety disorders.

This addition to our network allows our members greater access to the evidence-based treatment called exposure response prevention, or ERP, therapy, which is a sophisticated version of cognitive behavioral therapy.

CBT has been the first-line treatment for these disorders for many years. While CBT provides relief for many people, exposure response prevention therapy can be helpful when CBT isn’t effective.

Until now, we’ve had a small number of specialized providers that address OCD and phobias, but they’ve been largely focused around the Ann Arbor and Grand Rapids areas.

NOCD’s integrated treatment model pairs a network of master’s level licensed professionals with online adherence tools and a peer community. Professional staff includes licensed psychologists, counselors and social workers who are trained in using exposure response prevention therapy for OCD treatment.

NOCD provides:

• OCD-specific clinical diagnostic assessments in a video-based session
• Scheduled video-based teletherapy in all geographic locations
• Electronic messaging between the member and his or her NOCD professional

Other therapeutic tools include:

• Structured electronic-based exercises and tools to assist in the therapy process
• Support during any OCD episode
• The ability to view treatment data in a secure, centralized area
• An online, monitored peer support community to provide nonprofessional support and find resources to manage OCD

NOCD will also facilitate psychiatric consultation with a member’s provider for treatment intervention and coordination of care.

During the COVID-19 crisis, Blue Cross and BCN have allowed the use of telehealth services for all our providers. Overall, we’ve seen a 70% increase in the utilization of this type of care. NOCD uses telepsychotherapy and telemedicine visits exclusively, so this doesn’t limit their services geographically.

NOCD maintains an ongoing team of subject matter experts and OCD leading advisers. This includes individuals from the University of California, Los Angeles OCD treatment program; Yale Medical School; University of Southern California Medical School; University of Pennsylvania; Harvard Medical School and the University of Illinois, Chicago.

The addition of this provider adds to our network capacity and provides more evidence-based interventions for our membership. To make an appointment or refer a member, contact NOCD at 312-766-6780 or visit nocd.com.**

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Preauthorize CT exams of abdomen and pelvis separately

As part of Blue Cross Blue Shield of Michigan’s PPO Radiology Management Program, participating providers must contact AIM Specialty Health^® for prior authorization of non-emergency, outpatient imaging procedures.

Recently, Blue Cross has become aware of facilities performing both a CT of the abdomen and a CT of the pelvis when only one of these exams has been deemed medically necessary by AIM. It’s important to note that these exams are separate and distinct, and represented by different CPT codes. If a concurrent performance of these exams requires clinical review for the combination code, the ordering physician or provider must have the exam reviewed for medical necessity. From a clinical perspective, the two exams can be differentiated as follows:

• CT imaging of the abdomen covers sections obtained from the diaphragmatic dome through the iliac crests. This anatomy includes the liver, biliary tract, pancreas, spleen, ad renal glands, kidneys, proximal ureters, lymph nodes, stomach and portions of the intestinal tract.
• CT imaging of the pelvis extends from the iliac crests through the pubic symphysis and incudes the distal ureters, urinary bladder, lymph nodes, portions of the intestinal tract, as well as the prostate gland and seminal vesicles in males and the uterus, tubal structures and ovaries in females.

In many cases, concurrent or combined CT imaging of both anatomic areas aren’t required. For example, further characterization of one or more space-occupying liver lesions with triple-phase CT imaging doesn’t require a pelvic CT. Short term follow-up of an abnormality located in either the abdomen or pelvis doesn’t need imaging of the other anatomic region. In these cases, repeat combined imaging of both areas subject the patient to unnecessary radiation and is considered an ineffective use of medical resources.

There are several clinical reasons to perform combined abdominal and pelvic CT imaging. For example, evaluation of obstructive uropathy or work-up of acute intestinal tract abnormalities, such as suspected appendicitis or diverticulitis, may require imaging of both areas. AIM's clinical guidelines list further indications for combined imaging under the section titled “CT of the Abdomen & Pelvis." In these cases, the ordering provider should request clinical appropriateness reviews for both exams.

If it’s discovered that a concurrent and combined CT is medically necessary after the initial request for one of the separate abdomen or pelvis CT modality was already approved through AIM, you should  contact AIM to void the original request and request a medically necessity review through AIM’s provider portal before  the retro review period expires.

The computed tomography angiography, or CTA, also has an individual and concurrent modality. The CTA abdomen and pelvis are distinct from each other and have different medical necessity criteria. If a concurrent CTA is required, the actual combined procedure code should be requested for medical necessity review.

Health care providers providing the imaging should validate the exams included in the clinical review from the ordering provider before rendering the service, either by calling AIM at 1-800-728-8008 or accessing information online through AIM's provider portal at AIMSpecialtyHealth.com.

Hygieia can help Blue Cross members with Type 2 diabetes manage glucose levels

If Blue Cross Blue Shield of Michigan commercial or Medicare Plus Blue^SM members with Type 2 diabetes need help managing their glucose levels, you can refer them to Hygieia.

Hygieia’s d-Nav^® Insulin Management Program helps members achieve and maintain healthy A1c levels through virtual visits, telephone follow-ups and supplies by mail. This is especially important for members who are trying to manage their diabetes during times of crisis when they can’t leave their homes.

Hygieia also:

• Provides patients with handheld devices that translate glucose readings into personalized recommended insulin doses
• Teaches patients how to use the devices
• Has clinical specialists follow up with patients to offer encouragement, correct usage errors and triage as needed
• Sends the member back to you, the referring provider, for any issues that aren’t directly related to insulin management
• Gives you access to detailed data on each member you refer, which is accessible through a secure portal

To refer Blue Cross members to Hygieia:

• Email the member’s information to appointments@hygieia.com or fax it to 734‑249‑9650. Hygieia will reach out to the member to schedule an appointment.
• You or the member can call or text 734‑369‑9984 to request an appointment.

Learn more about Hygieia and the d-Nav program at hygieia.com.**

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

Starting July 1, 2020, Praluent and Repatha will no longer be designated as specialty drugs

Starting July 1, 2020, the PCSK9 inhibitor drugs Repatha^® and Praluent^® will no longer be designated as specialty drugs. This means members can fill prescriptions for these drugs at any retail pharmacy in our network. And, if their prescription drug benefit allows it, they can fill a 90-day supply.

Specialty drugs require special handling, administration or monitoring. Some can only be filled by a specialty pharmacy.

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 Blue Cross and BCN commercial members.

During April, May and June 2020, the following medical drugs had authorization requirement updates, site-of-care updates or both for Blue Cross commercial (PPO only) members:

** Will become a unique code
***A unique code was assigned to this drug on July 1, 2020. Prior to July 1, this drug was assigned to a not-otherwise-classified, or NOC, code.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list.

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. For PPO groups that don’t require members to participate in the programs, refer to the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. This list is available on the Blue Cross Drugs Covered Under the Medical Benefit page of the ereferrals.bcbsm.com website.

These changes don’t apply to 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.

Prior authorization lists changing for Medicare Plus Blue, BCN and BCN Advantage members

We’re adding authorization requirements for four specialty drugs covered under the medical benefit for Medicare Plus Blue^SM, BCN commercial and BCN Advantage^SM members. The drugs (listed below) will require authorization through AIM Specialty Health^®.

For dates of service on or after July 24, 2020:

• Trodelvy™ (sacituzumab govitecan-hziy; HCPCS codes J3490, J3590, J9999)
• Jelmyto™ (mitomycin; HCPCS codes J3490, J3590, J9999)
• Darzalex Faspro™ (daratumumab and hyaluronidase-fihj; HCPCS codes J3490, J3590, J9999)

For dates of service on or after Aug. 24, 2020:

• Imlygic^® (talimogene laherparepvec; HCPCS code J9325)

How to submit AIM authorization requests

• Call the Contact Center at 1-844-377-1278.
• Use the AIM ProviderPortal**

To learn more about the AIM ProviderPortal, check out their Frequently Asked Questions page** and register for an account.**

More about the authorization requirements
Authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

For more information on requirements related to drugs covered under the medical benefit, see:

• BCN: Blue Cross and BCN utilization management medical drug list and the Medical Oncology Program list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members

We’ll update these lists with the new drug information before the effective dates.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

URMBT’s Health & Well-Being Call program expands to include virtual visits

As we announced in a June Record article, Blue Cross Blue Shield of Michigan is using Signify Health for the UAW Retiree Medical Benefits Trust, or URMBT, Health & Well-Being Call program.

Through the program, a licensed doctor or nurse practitioner calls eligible URMBT subscribers and spouses to discuss their health status and identify any gaps in care. Starting June 1, Signify Health will offer members a virtual visit to conduct the wellness assessment. A virtual visit consists of audio and video components through a computer, tablet or smartphone.

These meetings include checks on the member’s well-being, an opportunity for the member to ask medical questions, and allows the practitioner to share information and care resources available to the member.
 
Signify Health will contact you if they are scheduled to call or virtually contact a patient who identifies you as their primary care physician. Following the call, Signify Health will send you a copy of the completed health assessment with any recommendations it  made to your patient regarding their health and follow-up care.

The program is available to URMBT members who have one of our Medicare Advantage plans (either Medicare Plus Blue^SM or BCN Advantage^SM), as well as newly retired URMBT members who have Blue Cross Blue Shield of Michigan’s Enhanced Care Plan, or ECP.

Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and Trading Partner IDs don’t change. 

Keep the following in mind when changes occur. You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization form if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity (EDI).
• Click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with the TPA and Provider Authorization form, click on Download step-by-step instructions for completing the TPA (PDF).

FEP supports prenatal care, well-child visits

Early prenatal care and frequent well-child visits have a significant impact on the start of a healthy life for children. That’s why the Blue Cross and Blue Shield Federal Employee Program^® offers benefits and incentives to encourage members to stay healthy.

Prenatal care

• Prenatal care visits are a covered benefit for all FEP Service Benefit Plan members: Standard Option, Basic Option and FEP Blue Focus.
• The Pregnancy Care Incentive Program is available to Standard and Basic Option members. The program encourages timely prenatal care by rewarding members with a Pregnancy Care Box when a signed medical record is received showing their first trimester visit.

The Pregnancy Care Box is also available to Standard and Basic Option members upon request. The box includes books, educational pamphlets, samples, coupons and clothing items for the baby. For more information, visit fepblue.org/maternity.

Breastfeeding support

All FEP Service Benefit Plan members have benefit coverage for breastfeeding education and individual coaching by a certified lactation consultant. These members can receive a free breast pump kit and milk storage bags from Caremark by calling 1-800-262-7890.

Well-child visits

Well-child visits are covered 100% for all FEP Service Benefit Plan members when seen by a Preferred provider.

Keeping track of immunizations and developmental milestones can be a lot for parents. The Centers for Disease Control and Prevention provides a helpful and simple chart on immunizations and developmental milestones for children from birth through 6 years old. Click here** to view and share with your patients.

Healthy Families program

Available to all FEP Service Benefit Plan members, the Healthy Families program provides activities and tools to teach children about weight management, nutrition, physical activity and personal well-being. Members can learn more about this program by visiting fepblue.org/wellness-resources-and-tools.

For more information on any of these incentives, benefits or support programs for FEP Service Benefit Plan members, visit fepblue.org or call Customer Service at 1-800-482-3600.

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

New webinar recordings of 2020 sessions now available

Provider Experience continues to offer training resources to help your clinical and administrative staff work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network. We’ve added recordings and videos of the following webinars to the Learning Opportunities section of web-DENIS:

• Blue Cross 201: Claims Appeals Overview
• e-referral Upgrades
• Hyaluronic Acid Knee Injections
• Medical benefit drugs: Prior authorization and claim submission scenarios (E-Learning)
  

To access recordings of the provider training webinars we’ve delivered so far in 2020 through web-DENIS, follow these steps:

For Blue Cross

1. Click on BCBSM Provider Publications and Resources.
2. Click on Newsletters & Resources.
3. Click on Provider Training under Popular Links.
4. Find the webinar you want in the Featured Links section.
5. For Medical benefit drugs, click on E-Learning under Quick Access.

For BCN

1. Click on BCN Provider Publications and Resources.
2. Click on Learning Opportunities under Other Resources.
3. Click on the link you want under 2020 Provider Training Webinars.

As additional training webinars become available, we’ll let you know about them through web-DENIS or The Record.

2020 InterQual^® criteria to be implemented Aug.

Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2020 InterQual criteria on Aug. 1, 2020, to make utilization management determinations. There is InterQual criteria for behavioral health services, as well as non-behavioral health services. However, for Blue Cross commercial members, New Directions, an independent company that provides behavioral health services for most Blue Cross members, uses its own criteria for making determinations.

Non-behavioral health services
We’ll use updated criteria for all levels of care to make utilization management determinations for requests to authorize non-behavioral health services, subject to review, for the following members:

• Blue Cross commercial
• Medicare Plus Blue^SM
• BCN commercial
• BCN Advantage^SM

When clinical information is requested for a medical or surgical admission or for other services, we require submission of the specific components of the medical record that validate that the request meets the criteria.

Blue Cross and BCN also use local rules — modifications of InterQual criteria — in making utilization management determinations. The 2020 local rules will also go into effect on Aug. 1, 2020.

You’ll be able to access the updated versions of the modifications (local rules), as applicable, for [Note to reviewers – updated criteria will be posted by June 26]:

• Blue Cross — on the Authorization Requirements & Criteria page in the Blue Cross section of our ereferrals.bcbsm.com website. You’ll see links to the criteria in both Blue Cross’ PPO and the Medicare Plus Blue PPO sections of that page. You can also find the 2020 InterQual criteria by the end of July within Provider Secured Services. After you log in, click BCBSM Provider Publications and Resources. Click Newsletters & Resources, click Clinical Criteria & Resources and scroll down to the section titled BCBSM modifications to InterQual criteria.
• BCN — on the Authorization Requirements & Criteria page in the BCN section of our ereferrals.bcbsm.com website. Look under the Referral and authorization information heading.

Refer to the table below for more specific information on which criteria are used in making determinations for various types of non-behavioral health authorization requests.

Note: The information in the table above applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by an independent company that provides services to Blue Cross Blue Shield of Michigan.

Behavioral health services
BCN commercial, BCN Advantage^SM and Medicare Plus Blue^SM will begin using the 2020 InterQual^® criteria for behavioral health utilization management determinations on Aug. 1.

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below.

Links to the updated versions of the modified criteria, local rules and medical policies will be available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com.

As noted earlier in this article, determinations for behavioral health services for Blue Cross commercial members are handled by New Directions, an independent company that provides behavioral health services for most Blue Cross members. New Directions uses its own Medical Necessity Criteria.

Reminder: Providers must submit authorization requests to TurningPoint for musculoskeletal surgical procedures for certain members

As we reported in the May issue  of The Record, you need to submit authorization requests for all surgical procedures related to musculoskeletal conditions to TurningPoint, starting June 1, for dates of service on or after July 1. (The original launch date of June 1 had moved to July 1 due to the COVID-19 pandemic.)

Some important reminders:

• This is effective for BCN commercial, BCN Advantage^SM and Medicare Plus Blue^SM members.
• Facilities should have an authorization number before scheduling surgery. The ordering physician or provider office must secure the authorization and provide the authorization number to the facility.
• For inpatient professional claims, make sure to include only the procedure codes authorized for musculoskeletal procedures on your claim.
• TurningPoint began accepting submitted authorization requests on June 1.

We’ll continue to offer webinar training for providers and facilities. Use the links below to register for webinars:

• Training for professional providers
• Training for facility providers
• Portal training (professional providers only)

Where to find more information
For more information about TurningPoint, see the ereferrals webpages for Blue Care Network and Blue Cross Blue Shield of Michigan.

You can find procedure codes for orthopedic and spinal procedures managed by TurningPoint on ereferrals.bcbsm.com. Here are the links:

• Orthopedic
• Spinal

You can also refer to the Frequently asked questions document on our ereferrals.bcbsm.com website.

Blue Cross, BCN add provider group that addresses OCD, phobias and anxiety disorders by telehealth to network

Blue Cross Blue Shield of Michigan and Blue Care Network recently added a new provider group, called NOCD, that uses telehealth to address obsessive-compulsive disorders, phobias and anxiety disorders.

This addition to our network allows our members greater access to the evidence-based treatment called exposure response prevention, or ERP, therapy, which is a sophisticated version of cognitive behavioral therapy.

CBT has been the first-line treatment for these disorders for many years. While CBT provides relief for many people, exposure response prevention therapy can be helpful when CBT isn’t effective.

Until now, we’ve had a small number of specialized providers that address OCD and phobias, but they’ve been largely focused around the Ann Arbor and Grand Rapids areas.

NOCD’s integrated treatment model pairs a network of master’s level licensed professionals with online adherence tools and a peer community. Professional staff includes licensed psychologists, counselors and social workers who are trained in using exposure response prevention therapy for OCD treatment.

NOCD provides:

• OCD-specific clinical diagnostic assessments in a video-based session
• Scheduled video-based teletherapy in all geographic locations
• Electronic messaging between the member and his or her NOCD professional

Other therapeutic tools include:

• Structured electronic-based exercises and tools to assist in the therapy process
• Support during any OCD episode
• The ability to view treatment data in a secure, centralized area
• An online, monitored peer support community to provide nonprofessional support and find resources to manage OCD

NOCD will also facilitate psychiatric consultation with a member’s provider for treatment intervention and coordination of care.

During the COVID-19 crisis, Blue Cross and BCN have allowed the use of telehealth services for all our providers. Overall, we’ve seen a 70% increase in the utilization of this type of care. NOCD uses telepsychotherapy and telemedicine visits exclusively, so this doesn’t limit their services geographically.

NOCD maintains an ongoing team of subject matter experts and OCD leading advisers. This includes individuals from the University of California, Los Angeles OCD treatment program; Yale Medical School; University of Southern California Medical School; University of Pennsylvania; Harvard Medical School and the University of Illinois, Chicago.

The addition of this provider adds to our network capacity and provides more evidence-based interventions for our membership. To make an appointment or refer a member, contact NOCD at 312-766-6780 or visit nocd.com.**

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Preauthorize CT exams of abdomen and pelvis separately

As part of Blue Cross Blue Shield of Michigan’s PPO Radiology Management Program, participating providers must contact AIM Specialty Health^® for prior authorization of non-emergency, outpatient imaging procedures.

Recently, Blue Cross has become aware of facilities performing both a CT of the abdomen and a CT of the pelvis when only one of these exams has been deemed medically necessary by AIM. It’s important to note that these exams are separate and distinct, and represented by different CPT codes. If a concurrent performance of these exams requires clinical review for the combination code, the ordering physician or provider must have the exam reviewed for medical necessity. From a clinical perspective, the two exams can be differentiated as follows:

• CT imaging of the abdomen covers sections obtained from the diaphragmatic dome through the iliac crests. This anatomy includes the liver, biliary tract, pancreas, spleen, ad renal glands, kidneys, proximal ureters, lymph nodes, stomach and portions of the intestinal tract.
• CT imaging of the pelvis extends from the iliac crests through the pubic symphysis and incudes the distal ureters, urinary bladder, lymph nodes, portions of the intestinal tract, as well as the prostate gland and seminal vesicles in males and the uterus, tubal structures and ovaries in females.

In many cases, concurrent or combined CT imaging of both anatomic areas aren’t required. For example, further characterization of one or more space-occupying liver lesions with triple-phase CT imaging doesn’t require a pelvic CT. Short term follow-up of an abnormality located in either the abdomen or pelvis doesn’t need imaging of the other anatomic region. In these cases, repeat combined imaging of both areas subject the patient to unnecessary radiation and is considered an ineffective use of medical resources.

There are several clinical reasons to perform combined abdominal and pelvic CT imaging. For example, evaluation of obstructive uropathy or work-up of acute intestinal tract abnormalities, such as suspected appendicitis or diverticulitis, may require imaging of both areas. AIM's clinical guidelines list further indications for combined imaging under the section titled “CT of the Abdomen & Pelvis." In these cases, the ordering provider should request clinical appropriateness reviews for both exams.

If it’s discovered that a concurrent and combined CT is medically necessary after the initial request for one of the separate abdomen or pelvis CT modality was already approved through AIM, you should  contact AIM to void the original request and request a medically necessity review through AIM’s provider portal before  the retro review period expires.

The computed tomography angiography, or CTA, also has an individual and concurrent modality. The CTA abdomen and pelvis are distinct from each other and have different medical necessity criteria. If a concurrent CTA is required, the actual combined procedure code should be requested for medical necessity review.

Health care providers providing the imaging should validate the exams included in the clinical review from the ordering provider before rendering the service, either by calling AIM at 1-800-728-8008 or accessing information online through AIM's provider portal at AIMSpecialtyHealth.com.

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 Blue Cross and BCN commercial members.

During April, May and June 2020, the following medical drugs had authorization requirement updates, site-of-care updates or both for Blue Cross commercial (PPO only) members:

** Will become a unique code
***A unique code was assigned to this drug on July 1, 2020. Prior to July 1, this drug was assigned to a not-otherwise-classified, or NOC, code.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list.

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. For PPO groups that don’t require members to participate in the programs, refer to the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. This list is available on the Blue Cross Drugs Covered Under the Medical Benefit page of the ereferrals.bcbsm.com website.

These changes don’t apply to 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.

Prior authorization lists changing for Medicare Plus Blue, BCN and BCN Advantage members

We’re adding authorization requirements for four specialty drugs covered under the medical benefit for Medicare Plus Blue^SM, BCN commercial and BCN Advantage^SM members. The drugs (listed below) will require authorization through AIM Specialty Health^®.

For dates of service on or after July 24, 2020:

• Trodelvy™ (sacituzumab govitecan-hziy; HCPCS codes J3490, J3590, J9999)
• Jelmyto™ (mitomycin; HCPCS codes J3490, J3590, J9999)
• Darzalex Faspro™ (daratumumab and hyaluronidase-fihj; HCPCS codes J3490, J3590, J9999)

For dates of service on or after Aug. 24, 2020:

• Imlygic^® (talimogene laherparepvec; HCPCS code J9325)

How to submit AIM authorization requests

• Call the Contact Center at 1-844-377-1278.
• Use the AIM ProviderPortal**

To learn more about the AIM ProviderPortal, check out their Frequently Asked Questions page** and register for an account.**

More about the authorization requirements
Authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

For more information on requirements related to drugs covered under the medical benefit, see:

• BCN: Blue Cross and BCN utilization management medical drug list and the Medical Oncology Program list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members

We’ll update these lists with the new drug information before the effective dates.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and Trading Partner IDs don’t change. 

Keep the following in mind when changes occur. You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization form if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity (EDI).
• Click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with the TPA and Provider Authorization form, click on Download step-by-step instructions for completing the TPA (PDF).

Reminder: We’ve postponed some pharmacy initiatives

As you may have read in a web-DENIS message in April, the effective dates for some pharmacy initiatives that we communicated about in The Record have been postponed due to our efforts to combat COVID-19.

The following are links to the original Record articles, published in March and April, containing effective dates that are no longer valid:

• Changes for medications that treat nausea and vomiting
• Changes for Soma products
• Changes for medications that treat migraines

Once the new effective dates for these initiatives have been established, we’ll communicate them through The Record.

Starting July 1, 2020, Praluent and Repatha will no longer be designated as specialty drugs

Starting July 1, 2020, the PCSK9 inhibitor drugs Repatha^® and Praluent^® will no longer be designated as specialty drugs. This means members can fill prescriptions for these drugs at any retail pharmacy in our network. And, if their prescription drug benefit allows it, they can fill a 90-day supply.

Specialty drugs require special handling, administration or monitoring. Some can only be filled by a specialty pharmacy.

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 Blue Cross and BCN commercial members.

During April, May and June 2020, the following medical drugs had authorization requirement updates, site-of-care updates or both for Blue Cross commercial (PPO only) members:

** Will become a unique code
***A unique code was assigned to this drug on July 1, 2020. Prior to July 1, this drug was assigned to a not-otherwise-classified, or NOC, code.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list.

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. For PPO groups that don’t require members to participate in the programs, refer to the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. This list is available on the Blue Cross Drugs Covered Under the Medical Benefit page of the ereferrals.bcbsm.com website.

These changes don’t apply to 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.

Prior authorization lists changing for Medicare Plus Blue, BCN and BCN Advantage members

We’re adding authorization requirements for four specialty drugs covered under the medical benefit for Medicare Plus Blue^SM, BCN commercial and BCN Advantage^SM members. The drugs (listed below) will require authorization through AIM Specialty Health^®.

For dates of service on or after July 24, 2020:

• Trodelvy™ (sacituzumab govitecan-hziy; HCPCS codes J3490, J3590, J9999)
• Jelmyto™ (mitomycin; HCPCS codes J3490, J3590, J9999)
• Darzalex Faspro™ (daratumumab and hyaluronidase-fihj; HCPCS codes J3490, J3590, J9999)

For dates of service on or after Aug. 24, 2020:

• Imlygic^® (talimogene laherparepvec; HCPCS code J9325)

How to submit AIM authorization requests

• Call the Contact Center at 1-844-377-1278.
• Use the AIM ProviderPortal**

To learn more about the AIM ProviderPortal, check out their Frequently Asked Questions page** and register for an account.**

More about the authorization requirements
Authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

For more information on requirements related to drugs covered under the medical benefit, see:

• BCN: Blue Cross and BCN utilization management medical drug list and the Medical Oncology Program list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members

We’ll update these lists with the new drug information before the effective dates.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Blue Cross and BCN will cover Truvada for HIV PrEP, starting in July

Effective July 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will cover HIV medication Truvada^® for pre-exposure prophylaxis with no cost share for most commercial members at high risk for HIV.

A generic version of Truvada is expected to be released in September 2020. At that time, only the generic version will be covered with no cost share. The cost for brand Truvada will depend on the member’s benefit.

Truvada and Descovy^® are the only two drugs indicated for HIV PrEP. If a member is newly prescribed Descovy for PrEP on or after May 1, 2020, we won’t cover the prescription unless prior authorization criteria are met. In such situations, prescribers should submit a prior authorization request. Otherwise, the prescription claim won’t be covered at the pharmacy.

We’ll only approve a prior authorization for Descovy for PrEP if there is documentation of a creatinine clearance (CrCl) less than 60 mL/min or osteoporosis.

Truvada and Descovy both contain tenofovir and emtricitabine. Each tenofovir component is formulated as a pro-drug.

Differences in pro-drug formulation and subsequent half-life don’t affect efficacy but can influence side effect profiles. Descovy demonstrated non-inferiority to Truvada in the DISCOVER trial, which means both drugs are equally effective in preventing the transmission of HIV-1.

Both drugs are contraindicated as PrEP in patients with unknown or positive HIV status. Using Descovy or Truvada for PrEP without confirmation of negative HIV status may increase the risk of developing HIV-1 resistance substitutions.

For members using Descovy to treat HIV, their normal cost share will apply.

Which members can receive this at $0 cost share?
This medication will be covered at $0 cost share for Blue Cross and BCN commercial members who are at high risk of contracting HIV. We’ll cover generic Truvada for PrEP at $0 cost share when it’s available. 
This change doesn’t apply to grandfathered employees, retirees or groups with religious accommodation exceptions.

Why are we doing this?
The U.S. Preventive Services Task Force has recommended that:

• Providers offer PrEP with effective antiretroviral therapy to patients at high risk for HIV.
• It must be offered with no cost share.

The Centers for Disease Control and Prevention reports that PrEP is highly effective for preventing HIV. Studies have shown that it reduces the risk of contracting HIV through sexual transmission by about 99% when taken daily. Among people who inject drugs, PrEP reduces the risk of getting HIV by at least 74% when taken daily. PrEP is much less effective if it isn’t taken consistently.

What is the USPSTF recommendation?
The following is the draft recommendation summary:

A grade of A or B means it must be offered as preventive at $0 cost share.

Who can prescribe PrEP?
Any licensed prescriber can prescribe PrEP. Specialization in infectious diseases or HIV medicine isn’t required. In fact, primary care providers who routinely see people at risk for HIV acquisition should consider offering PrEP to all eligible members.