Changes coming to infliximab step therapy requirements for Medicare Advantage members in January

For dates of service on or after Jan. 1, 2024, infliximab step therapy requirements are changing for Cimzia^®, Skyrizi^® IV and Ilumya^®. These changes apply to Medicare Plus Blue℠ and BCN Advantage℠ members.

Notes:

• These drugs are part of members’ medical benefits, not their pharmacy benefits.
• These drugs require prior authorization. Submit requests through the NovoLogix^® online tool.

Requirements added for Cimzia and Skyrizi

Starting Jan. 1, members will have to try and fail a preferred infliximab drug before a health care provider requests prior authorization for the following drugs:

• Cimzia (certolizumab pegol), HCPCS code J0717
• Skyrizi IV (risankizumab-rzaa), HCPCS code J2327

For information about preferred drug designations, see our provider alert, Update: Changes to preferred drug designations and prior authorization requirements for Medicare Advantage members.

Requirements removed for Ilumya

Starting Jan. 1, members won’t have to try and fail a preferred infliximab drug before using Ilumya.
Ilumya will continue to require prior authorization.

How to submit prior authorization requests

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.

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

The drugs mentioned above require prior authorization when they are administered by a 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.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.