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May 2020
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 covered under the medical benefit. As part of this effort, we maintain a comprehensive list of requirements for both PPO and HMO commercial members.
During January, February and March 2020, the following medical drugs had authorization requirement updates, site-of-care updates or both for Blue Cross’ PPO members:
| HCPCS code |
Brand name |
Generic name |
| J3590** |
Adakveo® |
crizanlizumab-tmca |
| J3490** |
Vyondys 53™ |
golodirsen |
| J3590** |
Avsola™ |
infliximab-axxqJ |
| J3490** |
Givlaari™ |
givosiran |
| J7170 |
Hemlibra® |
emicizumab-kxwh |
| J0222 |
Onpattro® |
patisiran |
| J1303 |
Ultomiris® |
avulizumab‑cwvz |
| J3111 |
Evenity® |
romosozumab-aqqg |
| J0178 |
Eylea® |
aflibercept |
| J2778 |
Lucentis® |
ranibizumab |
| J0179 |
Beovu® |
brolucizumab-dbll |
| J2503 |
Macugen® |
pegaptanib sodium |
| **Will become a unique code. |
For a detailed list of requirements, see the Blue Cross Drugs Covered Under the Medical Benefit page at ereferrals.bcbsm.com.
Additional notes
The authorization requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To view the list of PPO groups that don’t require members to participate in the program, see 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 at ereferrals.bcbsm.com.
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.
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