Blue Cross and BCN provide $0 cost sharing for COVID‑19 vaccine coverage

Blue Cross Blue Shield of Michigan and Blue Care Network are waiving all copays, deductibles and coinsurance for the administration of COVID-19 vaccines to all commercial members during the government’s multi-phased approach to vaccine distribution. Medicare is covering the vaccine costs for Medicare members.

To assist you, we’ve created a new document to support provider offices preparing for COVID-19 vaccines. The COVID-19 vaccine information for providers document includes guidelines on distribution, coverage, billing, reporting and more, using the most current information available.

We also encourage health care providers to review their list of patients to determine which ones are now eligible to receive the vaccine, and to consider reaching out to assist them in their efforts to obtain a vaccine.

You can find the COVID-19 vaccine information for providers document on the Coronavirus information updates for providers link on the on the BCBSM Newsletters and Resources and BCN Provider Publications and Resources pages of web-DENIS under COVID-19 vaccine information. It’s also on our public website at bcbsm.com/coronavirus.

For more information about our decision to provide COVID-19 vaccine coverage at 0% cost sharing, read the Blue Cross news release.

Addressing implicit bias in health care can improve care delivery

You might have heard that implicit bias plays a role in how health care is delivered in doctor’s offices, hospitals and other health care settings. But what exactly is meant by implicit bias?

Implicit bias refers to the attitudes, stereotypes and generalizations that affect our understanding, actions and decisions in an unconscious manner. It often results in  prejudices in favor of — or against — a thing, person or group.

“All human beings are wired to have bias, and biases are often based on assumptions and stereotypes that are learned over time,” explained Bridget Hurd, vice president of Inclusion and Diversity for Blue Cross Blue Shield of Michigan. “These unrealized or unconscious beliefs can affect our decision-making.”

In a health care setting, implicit bias can have dangerous consequences.

“Every medical professional is mission-driven to heal their patient, but research indicates that bias shows in various ways in the delivery of health care — more often implicitly rather than explicitly,” said President and CEO Daniel J. Loepp in a recent blog “It benefits all medical professionals to spend time working to recognize where implicit bias may be present in the delivery of care and developing approaches to address it to the benefit of patients everywhere.”

Consider these examples:

• Non-white patients presenting to the emergency room with the same symptoms as white Americans are less likely to receive pain medication, according to an article in Physician’s Weekly.

• An article published in the National Academy of Sciences reported that a survey of white medical students in 2016 showed that many had false beliefs about the biological differences between Blacks and whites, leading to different treatment recommendations.

• Early in the COVID-19 pandemic, reports indicated that African-Americans with concerning symptoms weren’t tested as often as their white counterparts, according to a review of billing information conducted by a biotech data firm.

Creating widespread understanding of these disparities in how health care delivery differs based on implicit bias is the first step in successfully addressing this issue.

That’s why Blue Cross is rolling out implicit bias education to health care providers over the next two years. It covers such topics as the science of bias, how it influences behaviors and patient outcomes, and how to make efforts to overcome implicit bias.

In September, leaders and staff at 40 physician organizations that participate in the Physician Group Incentive Program were introduced to implicit bias education. Next, it’s being rolled out to patient-centered medical home physicians and office staff.

“Creating awareness among physicians and office staff is an important step in building cultural competency and addressing gaps in care that may occur due to biases related to race, ethnicity, gender, sexual orientation, obesity or socioeconomic status,” said Hurd, who is leading the new Office of Health and Health Care Disparities.

Practices with PCMH designation will be required to take part in implicit bias educational opportunities this year to continue to receive value-based reimbursement tied to the PCMH designation.

Additionally, Gov. Gretchen Whitmer announced a directive last year that requires medical professionals to go through implicit bias training when obtaining or renewing their licenses.

Get ready for Availity: Technical requirements

This is part of a series of articles on Availity^®, the new provider portal that will become available later this year

As we’ve communicated previously, Blue Cross Blue Shield of Michigan and Blue Care Network will move to the Availity provider portal later in 2021. We want your organization to have the best experience possible when using Availity. For a smooth transition, you should have the following:

• A high-speed internet connection
• Google Chrome as your browser (Chrome is the preferred browser, but Microsoft Edge, version 79 or higher, and Firefox^® are also supported. Internet Explorer^®, version 11.0 or higher, is supported but not recommended.)
• The ability to enable pop-up windows, allow JavaScript and allow images to load automatically
• 1024 x 768 pixels or greater screen resolution
• Up-to-date antivirus software
• The latest version of Adobe^® Reader, to view PDF documents

Tip: The latest Availity technical requirements are available on the Availity website.** Scroll down and click on the Requirements tab.

Questions?

If you have questions about the move to Availity, check our Frequently Asked Questions document first. If your question isn’t already answered there, submit your question to ProviderPortalQuestions@bcbsm.com so we can consider adding it to the FAQ document. If you need immediate assistance or have a question specific to a certain member or situation, use our website resources or contact Provider Inquiry.

Web resources:

• Log in as a provider at bcbsm.com.
• Find prior authorization information for Michigan providers at ereferrals.bcbsm.com.
• Find prior authorization information for non-Michigan providers and medical policy information by going to bcbsm.com/providers and clicking on Quick Links.

Provider Inquiry numbers are available at bcbsm.com/providers:

• Click on Contact Us.
• Click on the type of provider you are.
• Click on Provider Inquiry.

Call the Blue Cross Web Support Help Desk at 1-877-258-3932 if you have problems with the current Blue Cross Provider Secured Services site.

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

2021 CPT and HCPCS Update now available

We recently created a new document, the 2021 CPT and HCPCS Update, to let you know about new and deleted CPT and HCPCS codes. It’s been posted on web-DENIS on the Clinical Criteria & Resources page.

As you may have read in the January Record, the Centers for Medicare & Medicaid Services had delayed the release of its 2021 HCPCS codes so we were only able to share a CPT Update document at that time.

This new document also includes updated information about the coverage decisions for certain CPT codes, so you’ll want to use it as your reference for new CPT and HCPCS codes for 2021. As future updates occur throughout the year, we’ll let you know via Record articles.

To access the 2021 CPT and HCPCS Update from web-DENIS, follow these steps:

1. Click on BCBSM Provider Publications and Resources.
2. Click on Newsletters and Resources.
3. Click on Clinical Criteria & Resources (or look under What’s New).
4. Scroll down to HCPCS and CPT Updates.

Blue Cross adds Billing/Claims page

At the end of 2020, we added a Billing/Claims page to the BCBSM Newsletters & Resources section of our secure website. It organizes useful billing and claims information and links on one convenient page for Blue Cross Blue Shield of Michigan commercial and Medicare Plus Blue℠. You’ll find:

• Provider manuals for Blue Cross commercial and Medicare Plus Blue
• User guides and job aids
• Commonly used forms
• Additional resources
  

Take a moment to discover all the information included on the new Blue Cross Billing/Claims page. Here’s how to find it:

1. Log in as a provider at bcbsm.com.
2. Click on BCBSM Provider Publications and Resources.
3. Click on Newsletters & Resources.
4. Under Popular Links, click on Billing/Claims.

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.

HEDIS medical record reviews begin in February

Each year from February through May, Blue Cross Blue Shield of Michigan conducts Healthcare Effectiveness Data and Information Set, or HEDIS^®, medical record reviews for members who live in Michigan. This year, Blue Cross’ HEDIS clinical consultants will conduct HEDIS reviews for members with Blue Cross PPO plans (including commercial, Medicare Plus Blue℠ and individual products) who had services in 2020.

As part of their efforts to support HEDIS and government-required programs, the Blue Cross and Blue Shield Association mandates who can retrieve medical records for patients living in Michigan but enrolled in another state’s Blue plan. Blue Cross is authorized to retrieve medical records for patients enrolled in a Blue Medicare Advantage PPO plan in another state.

Inovalon, an independent data and analytics firm, is authorized to retrieve medical records for patients enrolled in all Blue Cross commercial plans, as well as Blue Medicare Private Fee-for-Service and HMO plans.

For the HEDIS reviews, Blue Cross looks for details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results and colorectal screenings. This information helps us improve health care quality for our members.

Blue Cross’ HEDIS clinical consultants will contact you to schedule an appointment for a HEDIS review or request that you fax the necessary records. The HEDIS review also requires proof of service documentation for data collected from a medical record.

If you have questions or concerns, contact Laurie Latvis at llatvis@bcbsm.com.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance

CAHPS research offers insights into improving the patient experience

Research from the Consumer Assessment of Healthcare Providers and Systems, or CAHPS^®, survey can help providers better understand their Medicare patients’ needs and expectations. The Centers for Medicare & Medicaid Services annually compiles findings about improving the patient experience and understanding health outcomes through this survey.

You can access reports, articles and case studies through the Research on Improving the Patient Experience page** of the Agency for Healthcare Research and Quality website.

Check out the CAHPS survey tip sheet to learn more about why this annual survey is important, how it’s conducted, what questions are asked and ways you can successfully address care opportunities for patients.

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

Date change: CareCentrix to manage Medicare Advantage home health care prior authorizations starting June 1

As reported in the December 2020 issue of The Record and in the January-February 2021 issue of BCN Provider News, Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with CareCentrix^® to manage prior authorizations for home health care services for Medicare Plus Blue℠ and BCN Advantage℠ members.

We’re delaying the date on which this program will begin. CareCentrix will manage home health service authorizations for episodes of care starting on or after June 1, 2021.

For episodes of care that start before June 1, 2021, you don’t need to submit prior authorization requests for home health care services.

Telehealth visits, including annual wellness visits, available to Medicare Advantage patients

We encourage health care professionals to remind their Medicare Advantage patients that they can use telehealth services for appointments with their health care providers.

Remember that for all telehealth visits, the documentation in the office note must include the following information:

• Type of telehealth contact (for example, visual, audio, email or portal)
• Type of video service (for example, Skype, Zoom or BlueJeans)
• Location of patient and provider
• Patient-informed consent documented (in other words, he or she understands and accepts the privacy and security risks of telehealth medicine)

The following may also be documented for telehealth, telephone, e-visits and virtual check-ins:

• Patient self-reported blood pressure readings from any digital device
• Advanced illness and frailty exclusions

Keep in mind that Medicare Advantage patients can complete their free annual wellness visit in one of the following ways:

• A traditional face-to-face visit in your office
• An online telehealth visit using a smartphone, computer or tablet with audio and video capability
• A telephone-only visit for patients who don’t have video capability

The procedure codes are:

• G0402: Welcome to Medicare visit
• G0438: Annual wellness visit, initial
• G0439: Annual wellness visit, subsequent

For more information, view the Controlling Blood Pressure tip sheet and the Advanced Illness and Frailty Exclusions Guide.

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.

For nonpreferred filgrastim products, submit prior authorization requests using NovoLogix^® starting in April

For courses of treatment that start on or after April 1, 2021, you’ll need to submit prior authorization requests for all members for nonpreferred filgrastim products using the NovoLogix^® online tool.

As we’ve communicated previously, for courses of treatment that started Oct. 1, 2020, through March 31, 2021, you should submit requests to AIM Specialty Health^® for Blue Care Network commercial, Medicare Plus Blue℠ and BCN Advantage℠ members. And for Blue Cross Blue Shield of Michigan fully insured commercial members, for courses of treatment that started on or after Oct. 1, 2020, you’re already submitting these requests using NovoLogix so nothing will change.

Note: For commercial members, these requirements:

• 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 members covered by the Blue Cross and Blue Shield Federal Employee Program^®, the Michigan Education Special Services Association or UAW Retiree Medical Benefits Trust non-Medicare members

For details on the preferred and nonpreferred filgrastim products, refer to the August 2020 Record article.

As a reminder, authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Some drugs won’t be payable when administered by a health care provider to Blue Cross and BCN commercial members

For dates of service on or after April 1, 2021, the medications listed below won’t be payable by Blue Cross Blue Shield of Michigan and Blue Care Network when administered by a physician or other health care professional.

This change affects Blue Cross commercial and Blue Care Network commercial members. The reason for the change is that these drugs can safely and conveniently be self-administered by the member in the member’s home. They don’t require administration by a health care professional.

The following drugs are currently payable under either the medical benefit or the pharmacy benefit. Starting April 1, they’re payable only under the pharmacy benefit.

• Actimmune^® (interferon gamma-1b), HCPCS code J9216
• Akynzeo^® (netupitant / palonosetron), HCPCS code J8655
• Arcalyst^® (rilonacept), HCPCS code J2793
• Banophen™ / Ormir™ / Pharbedryl™ (diphenhydramine), HCPCS code Q0163
• Emend^® (aprepitant), HCPCS code J8501
• Imitrex^® (sumatriptan succinate), HCPCS code J3030
• Granisetron HCl^® (granisetron hydrochloride), HCPCS code Q0166 / S0091
• Marinol^® / Syndros^® (dronabinol), HCPCS code Q0167
• Megestrol acetate^®, HCPCS code S0179
• Pegasys^® (peginterferon alfa-2a), HCPCS code S0145
• Pegintron^® (peginterferon alfa-2b), HCPCS code S0148
• Promethazine HCl^® (phenadoz), HCPCS code Q0169
• Regranex^® (becaplermin), HCPCS code S0157
• Sensipar^® (cinacalcet), HCPCS code J0604
• Varubi^® (rolapitant), HCPCS code J8670
• Zofran^® / Zuplenz^® (ondansetron), HCPCS code Q0162 / S0119

There are no other changes that apply to the management of these therapies at this time.

For more information

To view requirements for drugs covered under the pharmacy benefit, see the Blue Cross and BCN Prior authorization and step therapy coverage criteria document. This document is available from the following pages on the ereferrals.bcbsm.com website:

• Blue Cross Pharmacy Benefit Drugs
• BCN Pharmacy Benefit Drugs

For a list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document.

We’ll update the requirements lists with the new information prior to April 1, 2021.

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 the fourth quarter of 2020, there were changes to prior authorization requirements, site-of-care requirements or both for Blue Cross commercial members for the following medical benefit drugs:

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

This list is available on the Blue Cross Medical Benefit Drugs page at ereferrals.bcbsm.com.

These 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. To view the list of Blue Cross commercial groups that don’t participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List.

As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Blue Cross offers additional mileage reimbursement for ground ambulance providers in 2021

During the first quarter of 2021, Blue Cross Blue Shield of Michigan and Blue Care Network are offering ground ambulance providers an opportunity to become eligible for additional reimbursement for mileage.

Ground ambulance providers who participate under the BCBSM and BCN Ambulance Provider Participation Agreement will be eligible for additional reimbursement associated with HCPCS code A0425. Reimbursement will depend on the number of providers who sign the agreement. This additional reimbursement is in addition to the 2.25% overall ambulance fee schedule increase for 2021.

The program will be reassessed every 12 months.

To receive this additional reimbursement, follow these steps:

• Sign the joint BCBSM and BCN Ambulance Provider Participation Agreement if you haven’t already done so.
• The signing period runs from Jan. 1 to March 31, 2021, for initial qualification.
• Receive an additional percentage reimbursement for mileage.
• The percentage will depend on the number of providers who sign the joint agreement (see table below).
• The appropriate additional reimbursement percentage will be applied to code A0425 beginning on April 1, 2021.

Reminder: AIM to handle prior authorization for some high-tech radiology services for Michigan FEP members

As we reported in the January issue of The Record, starting Feb. 1, 2021, AIM Specialty Health^® will handle select high-tech radiology services for Michigan Blue Cross and Blue Shield Federal Employee Program^® members receiving services in Michigan. AIM is an independent company that manages authorizations of select services for Blue Cross Blue Shield of Michigan.

Information about the AIM high-tech radiology prior authorization program for FEP members can be found on the ereferrals.bcbsm.com website.

To find the codes that require prior authorization through AIM for Michigan FEP members:

• Go to ereferrals.bcbsm.com.
• Click on Blue Cross on the blue bar.
• Click on AIM-Managed Procedures.
• Scroll down to Resources.
• Click on Radiology services for Michigan Blue Cross and Blue Shield Federal Employee Program^® members that requires authorization by AIM Specialty Health.

How to submit authorization requests

Submit authorization requests using one of the following methods:

• Online through the AIM provider portal**
• By calling AIM at 1-800-728-8008

As a reminder, requests should be submitted before the services are provided.

Note: Make sure to verify members have active coverage on the date of service and that services are covered under the FEP Blue Cross and Blue Shield Service Benefit Plan.

Additional information

Information about requesting authorization from AIM, including how to register for and use the AIM ProviderPortal℠,** can be found below.

• On our ereferrals.bcbsm.com website:
• Blue Cross AIM-Managed Procedures page

Questions?

If you have questions, call AIM at 1-800-728-8008 or visit the AIM website.** You can also contact your provider consultant.

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

Helping patients with medication management

Medication adherence can be challenging for patients with a chronic illness, such as asthma, cardiovascular disease, diabetes or hypertension. Unfortunately, not all patients take their medication as prescribed and may be reluctant to discuss their reasons with their doctor.

A complete and accurate medication list maintained by patients is the foundation for addressing medication management issues, according to the Agency for Healthcare Research and Quality. Keeping a medication list may help identify behaviors that put some patients at risk for overdosing, underdosing or missing doses.

Following are several online resources to help patients keep track of their prescribed and over-the-counter medications:

• My Medication Record is a one-page form by The National Council on Aging.
• Personal Medicine List is a four-page form by the Institute for Safe Medication Practices.
• My Medicine Record is a four-page form by the Food and Drug Administration.

Additional resources available to Blue Cross and Blue Shield Federal Employee Program^® members include:

• Personal Health Record, which stores members’ health care information to help them keep track of medical history, appointments, medications and more. Members can access the PHR in the MyBlue^® member portal at fepblue.org or the MyBlue^® app.
• Nurse line at 1-888-258-3432, which can be used 24/7 if they have questions about health-related issues, including medications.
• Telehealth services
• Online or phone visits with a board-certified primary care doctor or specialist 24/7
• Members can contact Teladoc^® by phone at 1-855-636-1579, online at fepblue.org/telehealth or by using the FEP MyBlue^® app
• Coordinated Care program at 1-800-775-BLUE (2583) for support in coordinating care to manage health conditions, including medications, at home

If you or your patients have questions about FEP support services and benefits, call the Customer Service line at 1-800-482-3600.

Reminder: Register for upcoming training webinars

Provider Experience is continuing its series of training webinars for health care providers and staff. The webinars are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

Here’s information on the upcoming training webinars:

The Blue Cross 201 webinar series provides an in-depth learning opportunity and builds on information shared in our Blue Cross 101: Understanding the Basics webinar. This new webinar reviews the processes and tools available when submitting claims.

The Autism Overview webinar reviews current processes related to providing services to members with autism.

Recordings of previous webinars are available through web-DENIS on the Blue Cross Provider Publications and Resources and BCN Provider Publications and Resources pages as follows:

Blue Cross Provider Publications and Resources

1. Log in to Provider Secured Services.
2. Click on BCBSM Provider Publications and Resources.
3. Click on BCBSM Newsletters and Resources.
4. Click on Provider Training.
5. In the Featured Links section of the page, check out 2020 Provider Training Webinars.

You can also get more information about online training, presentations and videos by clicking on the E-Learning icon at the top of the page.

BCN Provider Publications and Resources

1. Log in to Provider Secured Services.
2. Go to BCN Provider Publications and Resources.
3. Under Other Resources, click on Learning Opportunities.
4. Find the most recent webinars under 2020 Provider Training Webinars.

As additional training webinars become available, we’ll let you know via web-DENIS, The Record and BCN Provider News.

Date change: CareCentrix to manage Medicare Advantage home health care prior authorizations starting June 1

As reported in the December 2020 issue of The Record and in the January-February 2021 issue of BCN Provider News, Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with CareCentrix^® to manage prior authorizations for home health care services for Medicare Plus Blue℠ and BCN Advantage℠ members.

We’re delaying the date on which this program will begin. CareCentrix will manage home health service authorizations for episodes of care starting on or after June 1, 2021.

For episodes of care that start before June 1, 2021, you don’t need to submit prior authorization requests for home health care services.

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.

For nonpreferred filgrastim products, submit prior authorization requests using NovoLogix^® starting in April

For courses of treatment that start on or after April 1, 2021, you’ll need to submit prior authorization requests for all members for nonpreferred filgrastim products using the NovoLogix^® online tool.

As we’ve communicated previously, for courses of treatment that started Oct. 1, 2020, through March 31, 2021, you should submit requests to AIM Specialty Health^® for Blue Care Network commercial, Medicare Plus Blue℠ and BCN Advantage℠ members. And for Blue Cross Blue Shield of Michigan fully insured commercial members, for courses of treatment that started on or after Oct. 1, 2020, you’re already submitting these requests using NovoLogix so nothing will change.

Note: For commercial members, these requirements:

• 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 members covered by the Blue Cross and Blue Shield Federal Employee Program^®, the Michigan Education Special Services Association or UAW Retiree Medical Benefits Trust non-Medicare members

For details on the preferred and nonpreferred filgrastim products, refer to the August 2020 Record article.

As a reminder, authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Some drugs won’t be payable when administered by a health care provider to Blue Cross and BCN commercial members

For dates of service on or after April 1, 2021, the medications listed below won’t be payable by Blue Cross Blue Shield of Michigan and Blue Care Network when administered by a physician or other health care professional.

This change affects Blue Cross commercial and Blue Care Network commercial members. The reason for the change is that these drugs can safely and conveniently be self-administered by the member in the member’s home. They don’t require administration by a health care professional.

The following drugs are currently payable under either the medical benefit or the pharmacy benefit. Starting April 1, they’re payable only under the pharmacy benefit.

• Actimmune^® (interferon gamma-1b), HCPCS code J9216
• Akynzeo^® (netupitant / palonosetron), HCPCS code J8655
• Arcalyst^® (rilonacept), HCPCS code J2793
• Banophen™ / Ormir™ / Pharbedryl™ (diphenhydramine), HCPCS code Q0163
• Emend^® (aprepitant), HCPCS code J8501
• Imitrex^® (sumatriptan succinate), HCPCS code J3030
• Granisetron HCl^® (granisetron hydrochloride), HCPCS code Q0166 / S0091
• Marinol^® / Syndros^® (dronabinol), HCPCS code Q0167
• Megestrol acetate^®, HCPCS code S0179
• Pegasys^® (peginterferon alfa-2a), HCPCS code S0145
• Pegintron^® (peginterferon alfa-2b), HCPCS code S0148
• Promethazine HCl^® (phenadoz), HCPCS code Q0169
• Regranex^® (becaplermin), HCPCS code S0157
• Sensipar^® (cinacalcet), HCPCS code J0604
• Varubi^® (rolapitant), HCPCS code J8670
• Zofran^® / Zuplenz^® (ondansetron), HCPCS code Q0162 / S0119

There are no other changes that apply to the management of these therapies at this time.

For more information

To view requirements for drugs covered under the pharmacy benefit, see the Blue Cross and BCN Prior authorization and step therapy coverage criteria document. This document is available from the following pages on the ereferrals.bcbsm.com website:

• Blue Cross Pharmacy Benefit Drugs
• BCN Pharmacy Benefit Drugs

For a list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document.

We’ll update the requirements lists with the new information prior to April 1, 2021.

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 the fourth quarter of 2020, there were changes to prior authorization requirements, site-of-care requirements or both for Blue Cross commercial members for the following medical benefit drugs:

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

This list is available on the Blue Cross Medical Benefit Drugs page at ereferrals.bcbsm.com.

These 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. To view the list of Blue Cross commercial groups that don’t participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List.

As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Reminder: Register for upcoming training webinars

Provider Experience is continuing its series of training webinars for health care providers and staff. The webinars are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

Here’s information on the upcoming training webinars:

The Blue Cross 201 webinar series provides an in-depth learning opportunity and builds on information shared in our Blue Cross 101: Understanding the Basics webinar. This new webinar reviews the processes and tools available when submitting claims.

The Autism Overview webinar reviews current processes related to providing services to members with autism.

Recordings of previous webinars are available through web-DENIS on the Blue Cross Provider Publications and Resources and BCN Provider Publications and Resources pages as follows:

Blue Cross Provider Publications and Resources

1. Log in to Provider Secured Services.
2. Click on BCBSM Provider Publications and Resources.
3. Click on BCBSM Newsletters and Resources.
4. Click on Provider Training.
5. In the Featured Links section of the page, check out 2020 Provider Training Webinars.

You can also get more information about online training, presentations and videos by clicking on the E-Learning icon at the top of the page.

BCN Provider Publications and Resources

1. Log in to Provider Secured Services.
2. Go to BCN Provider Publications and Resources.
3. Under Other Resources, click on Learning Opportunities.
4. Find the most recent webinars under 2020 Provider Training Webinars.

As additional training webinars become available, we’ll let you know via web-DENIS, The Record and BCN Provider News.

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.

For nonpreferred filgrastim products, submit prior authorization requests using NovoLogix^® starting in April

For courses of treatment that start on or after April 1, 2021, you’ll need to submit prior authorization requests for all members for nonpreferred filgrastim products using the NovoLogix^® online tool.

As we’ve communicated previously, for courses of treatment that started Oct. 1, 2020, through March 31, 2021, you should submit requests to AIM Specialty Health^® for Blue Care Network commercial, Medicare Plus Blue℠ and BCN Advantage℠ members. And for Blue Cross Blue Shield of Michigan fully insured commercial members, for courses of treatment that started on or after Oct. 1, 2020, you’re already submitting these requests using NovoLogix so nothing will change.

Note: For commercial members, these requirements:

• 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 members covered by the Blue Cross and Blue Shield Federal Employee Program^®, the Michigan Education Special Services Association or UAW Retiree Medical Benefits Trust non-Medicare members

For details on the preferred and nonpreferred filgrastim products, refer to the August 2020 Record article.

As a reminder, authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Some drugs won’t be payable when administered by a health care provider to Blue Cross and BCN commercial members

For dates of service on or after April 1, 2021, the medications listed below won’t be payable by Blue Cross Blue Shield of Michigan and Blue Care Network when administered by a physician or other health care professional.

This change affects Blue Cross commercial and Blue Care Network commercial members. The reason for the change is that these drugs can safely and conveniently be self-administered by the member in the member’s home. They don’t require administration by a health care professional.

The following drugs are currently payable under either the medical benefit or the pharmacy benefit. Starting April 1, they’re payable only under the pharmacy benefit.

• Actimmune^® (interferon gamma-1b), HCPCS code J9216
• Akynzeo^® (netupitant / palonosetron), HCPCS code J8655
• Arcalyst^® (rilonacept), HCPCS code J2793
• Banophen™ / Ormir™ / Pharbedryl™ (diphenhydramine), HCPCS code Q0163
• Emend^® (aprepitant), HCPCS code J8501
• Imitrex^® (sumatriptan succinate), HCPCS code J3030
• Granisetron HCl^® (granisetron hydrochloride), HCPCS code Q0166 / S0091
• Marinol^® / Syndros^® (dronabinol), HCPCS code Q0167
• Megestrol acetate^®, HCPCS code S0179
• Pegasys^® (peginterferon alfa-2a), HCPCS code S0145
• Pegintron^® (peginterferon alfa-2b), HCPCS code S0148
• Promethazine HCl^® (phenadoz), HCPCS code Q0169
• Regranex^® (becaplermin), HCPCS code S0157
• Sensipar^® (cinacalcet), HCPCS code J0604
• Varubi^® (rolapitant), HCPCS code J8670
• Zofran^® / Zuplenz^® (ondansetron), HCPCS code Q0162 / S0119

There are no other changes that apply to the management of these therapies at this time.

For more information

To view requirements for drugs covered under the pharmacy benefit, see the Blue Cross and BCN Prior authorization and step therapy coverage criteria document. This document is available from the following pages on the ereferrals.bcbsm.com website:

• Blue Cross Pharmacy Benefit Drugs
• BCN Pharmacy Benefit Drugs

For a list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document.

We’ll update the requirements lists with the new information prior to April 1, 2021.

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 the fourth quarter of 2020, there were changes to prior authorization requirements, site-of-care requirements or both for Blue Cross commercial members for the following medical benefit drugs:

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

This list is available on the Blue Cross Medical Benefit Drugs page at ereferrals.bcbsm.com.

These 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. To view the list of Blue Cross commercial groups that don’t participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List.

As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.