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 commercial and BCN commercial members.

During January, February and March 2021, there were changes to prior authorization requirements, site-of-care requirements or both for Blue Cross and BCN commercial members for the following medical benefit drugs:

• Amondys 45^® (casimersen), HCPCS code J3490
• Oxlumo™ (lumasiran), HCPCS code J3490
• Breyanzi^® (lisocabtagene-maraleucel), HCPCS code J9999

Note: The codes shown above will become unique codes.

For Blue Cross commercial members, 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 require members to participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list. Links to this list are also available on the Blue Cross Medical Benefit Drugs and BCN Medical Benefit Drugs pages of the ereferrals.bcbsm.com website.

Approval of an authorization request isn’t a guarantee of payment. As always, health care providers should verify eligibility and benefits for members.