Hemgenix and Tzield require prior authorization for Medicare Advantage members

For dates of service on or after Dec. 2, 2022, we require prior authorization for Medicare Plus Blue℠ and BCN Advantage℠ members for the following drugs covered under the medical benefit:

• Hemgenix^® (etranacogene dezaparvovec-drlb), HCPCS code J3590
• Tzield™ (teplizumab-mzwv), HCPCS code J3590

A prior authorization requirement also applies to most Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. See this provider alert for more information.

Submit prior authorization requests through NovoLogix^®

Submit prior authorization requests for Hemgenix and Tzield through the NovoLogix online tool. It offers real-time status checks and immediate approvals for certain medications.

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.

To request access to our provider portal, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

When prior authorization is required

These medications require prior authorization when they’re administered by a health care provider in sites of care such as outpatient facilities or physicians’ 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 by using the UB04 claim form for a hospital outpatient type of bill 013x

List of requirements

For a full outline of requirements related to drugs covered under the medical benefit for our Medicare Advantage members, refer to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

We’ve updated this list to reflect the change for Hemgenix and Tzield.

You can access this list and other information about requesting prior authorization at ereferrals.bcbsm.com on these pages:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

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

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