Fylnetra now requires prior authorization for Medicare Advantage members

For dates of service on or after Dec. 19, 2022, we require prior authorization for Fylnetra^® (pegfilgrastim-pbbk), HCPCS code J3590, for our Medicare Advantage members (both Medicare Plus Blue℠ and BCN Advantage℠ members). This drug is part of members’ medical benefits, not their pharmacy benefits.

Submit prior authorization requests through the NovoLogix^® online tool.

When prior authorization is required

This medication requires prior authorization when it’s administered by a health care provider in sites of care such as outpatient facilities or physicians’ offices, and is 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 by using the UB04 claim form for a hospital outpatient type of bill 013x

Submit prior authorization requests through the NovoLogix tool

To access NovoLogix, 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. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage on bcbsm.com/providers.

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.

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

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