We’ve changed how we manage Skyrizi SC, Stelara SC

For dates of service on or after Aug. 15, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network changed how we manage the following medications for our Medicare Advantage members:

• Skyrizi^® SC (risankizumab-rzaa), HCPCS code J3590
• Stelara^® SC (ustekinumab), HCPCS code J3357

This change applies to our Medicare Plus Blue℠ and BCN Advantage℠ members.

Note: This change doesn’t affect Skyrizi IV, HCPCS code J3590, and Stelara IV, HCPCS code J3358, which will continue to be managed as part of members’ Part B medical benefits.

What changed

For dates of service on or after Aug. 15, Medicare Plus Blue and BCN Advantage members who previously received Skyrizi SC or Stelara SC under the Part B medical benefit are required to continue their treatment under their Part D pharmacy benefits.

We made this change because these therapies can be safely and conveniently self-administered at home. The Centers for Medicare and Medicaid Services added these medications to the Self-Administered Drug Exclusion List: (SAD List).**

As a result:

• These drugs are no longer covered when administered by a doctor or other health care professional under the Part B medical benefit.
• Skyrizi SC isn’t included in our Medicare Advantage Part D formularies, but health care providers can request prior authorization for it as an exception. (See the “How to submit prior authorization requests for Skyrizi SC and Stelara SC” section of this article.)
• Note: Skyrizi IV still requires prior authorization through the Part B medical benefit, using the NovoLogix^® web tool.
• Stelara SC is now covered only through Medicare Advantage members’ Part D prescription drug plans. Prior authorization continues to be required through members’ Part D benefits. (See the “How to submit prior authorization requests for Skyrizi SC and Stelara SC ” section of this article.)

Note: Stelara IV still requires prior authorization through the Part B medical benefit, using the NovoLogix web tool. 

• Your patients can obtain these medications at pharmacies that dispense specialty drugs. They can also obtain these drugs through an AllianceRx Walgreens Pharmacy.

Note: For members who don’t have Part D pharmacy benefits through Blue Cross or BCN, health care providers need to work with the independent pharmacy company that provides the member’s Part D coverage.

How to submit prior authorization requests for Skyrizi SC and Stelara SC

For members who have Part D pharmacy benefits through Medicare Plus Blue or BCN Advantage, providers need to submit prior authorization requests for Skyrizi SC and Stelara SC as follows: 

• Electronically: Through CoverMyMeds^® or another free ePA tool, such as Surescripts^® or ExpressPAth^®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF) for more information.
• By phone: Call 1-800-437-3803 and follow the prompts for medications billed through the pharmacy benefit.
• By fax: 
• For Medicare Plus Blue requests, fax to 1-866-601-4428.
• For BCN Advantage requests, fax to 1-800-459-8027.

List of requirements

For a full 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 commercial and BCN commercial members. We’ve updated this list to reflect the changes related to these drugs.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

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