Xenpozyme, Zynteglo require prior authorization for Medicare Advantage members

For dates of service on or after Nov. 1, 2022, we’ve added a prior authorization requirement for Medicare Plus Blue℠ and BCN Advantage℠ members for the following medications:

• Xenpozyme™ (olipudase alfa-rpcp), HCPCS code J3590
• Zynteglo^® (betibeglogene autotemcel), HCPCS code J3590

Submit prior authorization requests through the NovoLogix^® online tool.

These medications are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These medications require prior authorization when they’re administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

• 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

Submit prior authorization requests through the NovoLogix tool

To access NovoLogix, log in to our provider portal (availity.com**), click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage on bcbsm.com/providers.

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.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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