Changes coming to preferred products for drugs covered under the medical benefit for most members

For dates of service on or after April 1, 2021, we’re designating certain medications as preferred products. This change will affect most Blue Cross Blue Shield of Michigan commercial and all Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

Here’s what you need to know when prescribing these products:

• Preferred products vary based on members’ health care plans.
• For members who start treatment on or after April 1, prescribe preferred products when possible. (See the “Submitting requests for prior authorization” section of this article for details.)
• For members who receive nonpreferred products for bevacizumab, trastuzumab and rituximab for courses of treatment that start before April 1, they can continue using the nonpreferred product until their authorizations expire. (We’ll contact our commercial members who receive these nonpreferred products and encourage them to discuss treatment options with you.)

Note: For commercial members, the requirements outlined in this article:

• Apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs covered under the medical benefit
• Do not apply to UAW Retiree Medical Benefits Trust non-Medicare members or to members covered by the Blue Cross and Blue Shield Federal Employee Program^® or MESSA.

Preferred and nonpreferred products

We’re designating the following products as preferred and nonpreferred for Blue Cross commercial fully insured groups, Blue Cross commercial members with individual coverage, Medicare Plus Blue members, BCN commercial members and BCN Advantage members:

Bevacizumab (reference product: Avastin^®)

• Preferred products:
• Mvasi™ (bevacizumab-awwb), HCPCS code Q5107
• Zirabev^® (bevacizumab-bvzr), HCPCS code Q5118
• Nonpreferred product: Avastin (bevacizumab), HCPCS code J9035

Rituximab (reference product: Rituxan^®)

• Preferred products:
• Ruxience™ (rituximab-pvvr), HCPCS code Q5119
• Riabni™ (rituximab-arrx), HCPCS code J3590 (will become a unique code)
• Nonpreferred products:
• Rituxan (rituximab), HCPCS code J9312
• Truxima^® (rituximab-abbs), HCPCS code Q5115

Trastuzumab (reference product: Herceptin®)

• Preferred products:
• Kanjinti™ (trastuzumab-anns), HCPCS code Q5117
• Trazimera™ (trastuzumab-qyyp), HCPCS code Q5116
• Nonpreferred products:
• Herceptin (trastuzumab), HCPCS code J9355
• Herzuma^® (trastuzumab-pkrb), HCPCS code Q5113
• Ogivri^® (trastuzumab-dkst), HCPCS code Q5114
• Ontruzant^® (trastuzumab-dttb), HCPCS code Q5112

Additional preferred and nonpreferred products for most commercial members

We’re designating the following products as preferred and nonpreferred for Blue Cross commercial fully insured groups, Blue Cross commercial members with individual coverage and BCN commercial members.

Pegfilgrastim (reference product: Neulasta^®)

• Preferred products:
• Neulasta/Neulasta Onpro^® (pegfilgrastim), HCPCS code J2505
• Nyvepria™ (pegfilgrastim-apgf), HCPCS code J3590
• Nonpreferred products
• Fulphila^® (pegfilgrastim-jmdb), HCPCS code Q5108
• Udenyca^® (pegfilgrastim-cbqv), HCPCS code Q5111
• Ziextenzo™ (pegfilgrastim-bmez), HCPCS code Q5120

Additional preferred and nonpreferred products for Medicare Advantage members

We’re designating the following products as preferred and nonpreferred for Medicare Plus Blue members and BCN Advantage members: 

Pegfilgrastim (reference product: Neulasta)

• Preferred products:
• Neulasta/Neulasta Onpro^® (pegfilgrastim), HCPCS code J2505
• Udenyca^® (pegfilgrastim-cbqv), HCPCS code Q5111
• Nonpreferred products:
• Fulphila^® (pegfilgrastim-jmdb), HCPCS code Q5108
• Ziextenzo™ (pegfilgrastim-bmez), HCPCS code Q5120
• Nyvepria™ (pegfilgrastim-apgf), HCPCS code J3590

Submitting requests for prior authorization

Here’s how to submit prior authorization requests for preferred products and nonpreferred products.

• For select preferred products: These products require prior authorization through AIM Specialty Health^®. Submit the request through the AIM provider portal** or by calling the AIM Contact Center at 1-844-377-1278. For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page** on the AIM website.
• For nonpreferred products — for members who must take nonpreferred products: These products have authorization requirements. Submit the prior authorization request through the NovoLogix online tool. NovoLogix offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you can 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.

Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Lists of requirements

See the following lists to view requirements for these products.

For commercial members:

• Standard commercial medical drug program — Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document
• Medical oncology drug program — Medical oncology prior authorization list for Blue Cross commercial fully insured members and BCN commercial members

For Medicare Advantage members, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

We’ll update the requirements lists with the new information before April 1.

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