Changes to preferred drug designations and prior authorization requirements for Medicare Advantage members

For dates of service on or after Jan. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to the preferred and nonpreferred designations for some medical benefit drugs.

In addition, health care providers will need to submit prior authorization requests through different systems for some preferred and nonpreferred drugs.

These changes will affect most Medicare Plus Blue℠ members and BCN Advantage℠ members.

Preferred drug designations are changing

Starting Jan. 1, we’re changing preferred drug designations as shown in the following table.

Changes are in bold text.

How to submit prior authorization requests

Submit prior authorization requests as follows:

• Preferred oncology drugs will require prior authorization through Carelon Medical Benefits Management. All other preferred drugs will require prior authorization through the NovoLogix^® online tool.
• Nonpreferred drugs will require prior authorization through NovoLogix.

Note: Preferred infliximab and rituximab agents don’t require prior authorization.

Reminder: Bevacizumab agents don’t require prior authorization for use in retinal disorders.

To submit a prior authorization request, 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. Then click on the tile to access the appropriate NovoLogix tool or the Carelon ProviderPortal.

Note: If you need to request access to Availity^® Essentials, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

When prior authorization is required

These drugs will require prior authorization when they’re administered by a health care provider in sites of care such as outpatient facilities or physician offices and are 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

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 and BCN Advantage members.

We’ll update the list to reflect these changes prior to the effective date.

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

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services. For more information, go to our ereferrals.bcbsm.com website.

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