Medicare Part B medical specialty drug prior authorization list changing in January 2021

We’re adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue℠ and BCN Advantage℠ members. The specialty medications on this list are administered by a health care professional in a provider’s office, at the member’s home, in an off-campus outpatient hospital or in an ambulatory surgical center (place of service 11, 12, 19, 22 and 24).

For dates of service on or after Jan. 1, 2021, the following CAR-T medications will require prior authorization through the NovoLogix^® online tool:

• Yescarta^® (axicabtagene ciloleucel), HCPCS code Q2041
• Kymriah^® (tisagenlecleucel), HCPCS code Q2042
• Tecartus™ (brexucabtagene autoleucel), HCPCS code J9999

The following medication will also require prior authorization through NovoLogix for dates of service on or after Jan. 1, 2021:

• Viltepso™ (viltolarsen), HCPCS codes J3490, J3590

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 service or as an outpatient facility service:

• 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

Important reminder
For these 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.

If you need 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.