Cimerli now requires prior authorization for Medicare Advantage members

For dates of service on or after Oct. 3, 2022, we’ve added a prior authorization requirement for Medicare Plus Blue℠ and BCN Advantage℠ members for the following drug:

• Cimerli™ (ranibizumab-eqrn), HCPCS code J3590

For Lucentis^®, Cimerli is the second biosimilar and the first interchangeable biosimilar.

Both Cimerli and Lucentis will continue to require the member to first try and fail Avastin^® (bevacizumab).

The HCPCS codes for Avastin are J3590 for Medicare Plus Blue and J9035 for BCN Advantage.

As a reminder, Lucentis already requires prior authorization. Avastin doesn’t require prior authorization when used for retinal conditions.

All these drugs are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

Cimerli requires prior authorization when it’s 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 using the UB04 claim form for a hospital outpatient type of bill 013x

Submit prior authorization requests through the NovoLogix tool

If you have access to the Availity Essentials provider portal (availity.com**), you already have access to NovoLogix. If you need to request access to Availity^®, follow the instructions on the Register for webtools webpage at bcbsm.com/providers.

After you’ve logged in to Availity, click on Payer Spaces and then on the BCBSM and BCN logo. This will take you to the Blue Cross and BCN payer space, where you’ll find links to the NovoLogix tools on the Applications tab. 

Reminder about requirements for other retinal drugs

As a reminder, all other intravitreal medications for retinal conditions continue to have Avastin as a step therapy requirement. These are:

• Eylea^® (aflibercept), HCPCS code J0178
• Beovu^® (rolucizumab-dbll), HCPCS code J0179
• Vabysmo^® (facricimab-svoa), HCPCS codes C9097 and J3590
• Byooviz^® (ranibizumab-nuna) HCPCS code Q5124
• Susvimo™ (ranibizumab injection, for ocular implant), HCPCS code J2779

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.
We’ve updated the list to reflect these changes.

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.