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March 2020

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.

From July 2019 to December 2019, the following medical drugs had authorization requirements updates, site-of-care updates or both:

HCPCS code Brand name Generic name
J0179 Beovu® Brolucizumab-dbll
J0598 Cinryze® C1 esterase inhibitor
J3111 Evenity™ Romosozumab-aqqg
J0641 Fusilev®

Levoleucovorin
J0642 Khapzory™ Levoleucovorin
Various Immune globulin products Immune globulin
Q5103 Inflectra® Infliximab-dyyb
J0202 Lemtrada™ Alemtuzumab
J1745 Remicade® Infliximab
Q5104 Renflexis® Infliximab-abda
J2350 Ocrevus® Ocrelizumab
J3490**/J3590** Scenesse® Afamelanotide
J3490**/J3590** Skyrizi™ Risankizumab-rzaa
J2323 Tysabri® Natalizumab
J3490**/J3590** Zolgensma® Onasemnogene abeparvovec-xioi

**Will become a unique code.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list. You can access this list from the following pages on the ereferrals.bcbsm.com website.

Additional notes
Authorization requirements apply only to groups that currently participate 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:

  1. Go to bcbsm.com/providers.
  2. Log in to Provider Secured Services.
  3. Click on BCBSM Provider Publications and Resources.
  4. Click on Newsletters & Resources.
  5. Click on Forms.
  6. Click on Physician administered medications.
  7. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

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.

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 2019 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.