Generic pemetrexed requires prior authorization for Medicare Advantage members

For dates of service on or after Jan. 1, 2023, the following drug requires prior authorization through AIM Specialty Healthl^®:

• Generic pemetrexed, HCPCS code J9314

As a reminder, we previously communicated the following requirements for brand-name drugs:

• Alimta^® (pemetrexed), HCPCS code J9305, requires prior authorization through AIM
• Pemfexy^® (pemetrexed), HCPCS code J9304, requires prior authorization through AIM for dates of service on or after Feb. 9, 2023

These requirements apply to Medicare Plus Blue℠ and BCN Advantage℠ members. These medications are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These drugs require prior authorization when administered by a health care provider in an outpatient facility or physician’s office and 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

How to submit authorization requests

Submit prior authorization requests to AIM using one of the following methods:

• Through the AIM ProviderPortal, which you can access by doing one of the following:
• Logging in to our provider portal (availity.com),** clicking on Payer Spaces and then clicking on the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space where you’ll click on the AIM ProviderPortal tile.
• Logging in directly to the AIM ProviderPortal at providerportal.com**
• Calling the AIM Contact Center at 1-844-377-1278

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.

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

AIM Specialty Health is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage 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.