Updates to preferred products for drugs covered under the medical benefit

We’ve designated certain medications as preferred products for dates of service on or after April 1, 2021. This change affects most Blue Cross Blue Shield of Michigan commercial, all Medicare Plus Blue^SM, all Blue Care Network commercial and all BCN Advantage^SM members.

We originally announced this information in a previous edition of The Record. But since that time, we’ve updated some of the guidelines. To make sure you’re aware of the revisions, we’ve marked the updated information with two asterisks (**).

Here’s what you need to know when prescribing these products for dates of service on or after April 1:

• Preferred products vary based on members’ health plans. Be sure to read this entire article for complete information.
• For members who start treatment on or after April 1: Prescribe preferred products when possible. You can find information on how to submit prior authorization requests for both preferred products and nonpreferred products in the “Submitting requests for prior authorization” section of this article.
• Note: Members who receive nonpreferred products for bevacizumab, trastuzumab or rituximab, for courses of treatment that start before April 1 can continue treatment using the nonpreferred product until their authorizations expire. We’ll reach out to commercial members who receive these nonpreferred products and encourage them to discuss treatment options with you.
• **For members who receive nonpreferred products for pegfilgrastim: These members should have transitioned to a preferred product by April 1.
• **For members who receive a bevacizumab product through intravitreal administration on or after April 1: Prior authorization won’t be required for intravitreal administrations for diagnoses associated with ocular conditions and don’t currently require prior authorization. As a reminder, follow the appropriate billing practices when submitting a claim for intravitreal bevacizumab for ocular conditions.
• For BCN commercial members, use HCPCS code J9035
• For Blue Cross commercial members, use HCPCS code J3590
• For Medicare Plus Blue members, use HCPCS code J3590
• For BCN Advantage members, use HCPCS code J9035

Information for Blue Cross commercial members

The requirements outlined in this article apply as follows:

• These requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization program for drugs covered under the medical benefit.
• These requirements don't apply to members covered by the Blue Cross and Blue Shield Federal Employee Program^® or to UAW Retiree Medical Benefits Trust non‑Medicare members.
• For Michigan Education Special Services Association and Blue Cross commercial self-funded groups:**
• For preferred products: These groups don’t participate in the AIM Specialty Health^® oncology management program. Because of this, you don’t need to request prior authorization for members who have coverage through these groups.
• For nonpreferred products: You’ll need to request prior authorization through the NovoLogix^® online tool for members who have coverage through these groups.
• Note: Previous communications incorrectly stated that these requirements don’t apply to MESSA. Disregard those communications, and follow the guidelines outlined above. 

Preferred and nonpreferred products for most members

We’re designating the following products as preferred and nonpreferred for:

• Blue Cross commercial fully insured and self-funded groups
• Blue Cross commercial members with individual coverage
• Medicare Plus Blue members
• BCN commercial members
• BCN Advantage members

¹ Preferred rituximab products don’t require authorization through AIM Specialty Health.

² Will become a unique code.

³ For BCN commercial, Medicare Plus Blue and BCN Advantage members: For courses of treatment that started Oct. 1, 2020, through March 31, 2021, submit these requests to AIM. For courses of treatment that started on or after April 1, 2021, submit these requests through NovoLogix.

⁴ For Blue Cross commercial fully insured members and Blue Cross commercial members with individual coverage: For courses of treatment that started on or after Oct. 1, 2020, you’re already submitting these requests through NovoLogix; your process won’t change.

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 and self‑funded groups
• Blue Cross commercial members with individual coverage
• BCN commercial members

Additional preferred and nonpreferred products for Medicare Advantage members

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

Submitting requests for prior authorization

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

• For preferred products: These products require prior authorization through AIM. Submit the request through the AIM ProviderPortal*** 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.

Exception:** Ruxience and Riabni don’t require authorization.

Note: Previous communications incorrectly stated that Ruxience and Riabni require prior authorization. Disregard those communications, and use this information.

• Nonpreferred products: These products have authorization requirements. Submit the prior authorization request through NovoLogix. NovoLogix offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services at bcbsm.com, 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.

Authorization isn’t a guarantee of payment. As always, 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, see the following two lists:
• 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 PPO (commercial) fully insured and BCN HMO (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.

**This information has been updated since it originally appeared in a previous edition of The Record.

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