Additional drugs to have requirements for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after Nov. 1, 2022, the following drugs will require prior authorization through either the NovoLogix^® online tool or AIM Specialty Health^® and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. The drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table for more information. When a cell is blank, the drug doesn’t have that requirement.

Brand name	Generic name	HCPCS code	HCPCS code	Requirements
				Prior authorization	Site of care	Quantity limits
Byooviz®	ranibizumab-nuna	Q5124	NovoLogix	✓		✓
Carvykti™	ciltacabtagene autoleucel	J9999, C9098	NovoLogix	✓		✓
Evkeeza™	evinacumab-dgnb	J1305	NovoLogix	✓		✓
Kimmtrak®	tebentafusp-tebn	J9999, C9095	AIM	✓
Oxlumo®	lumarisan	J0224	NovoLogix	✓		✓
Vabysmo®	faricimab-svoa	J3590, C9097	NovoLogix	✓		✓
Vyvgart®	efgartigimod alfa-fcab	J9332	NovoLogix	✓	✓

Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

Submit prior authorization requests through NovoLogix or AIM, as specified above.

If you have access to our provider portal (availity.com**), log in to Availity^®, click Payer Spaces and then click the BCBSM and BCN logo. This will take you to the Blue Cross and BCN payer space, where you can click the appropriate tile on the Applications tab.

If you need to request access to Availity, follow the instructions on the Register for webtools webpage at bcbsm.com/providers.

More about the authorization requirements

Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans, see:

• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members

We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date.

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

AIM Specialty Health is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services.