Byooviz to be preferred ranibizumab drug for Medicare Advantage members, starting Oct. 4

For dates of service on or after Oct. 4, 2022, for our Medicare Advantage (Medicare Plus Blue℠ and BCN Advantage℠) members, we’re designating preferred and nonpreferred ranibizumab products:

• Preferred: Byooviz^® (ranibizumab-nuna), HCPCS code Q5124
• Nonpreferred: Lucentis^® (ranibizumab), HCPCS code J2778

What’s changing?

Providers will need to show they’ve tried Byooviz as a step therapy requirement before requesting authorization to use Lucentis. This change goes into effect for dates of service on or after Oct. 4, 2022.

Both Byooviz and Lucentis will still require that the member first try and fail Avastin (bevacizumab), HCPCS code J3590 for Medicare Plus Blue and HCPCS code J9035 for BCN Advantage. Avastin doesn’t require prior authorization when used for retinal conditions.

These drugs are covered under members’ medical benefits.

Prior authorization still required

Lucentis and Byooviz will continue to require prior authorization when administered in any site of care other than inpatient hospital (place of service code 21) and billed as follows:

• 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

Submitting prior authorization requests

Submit prior authorization requests for Byooviz and Lucentis using the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

If you have access to the AvailityEssentials 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 on 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 still 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
• 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'll update the list to reflect these changes prior to the effective date.

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