Requirements for some medical benefit drugs change for most members

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper use of high-cost medications billed under the medical benefit. As part of this effort, we maintain comprehensive lists of requirements for our members.

In January through March 2023, we added requirements for some medical benefit drugs.

For Blue Cross commercial and BCN commercial members: We added prior authorization requirements and site-of-care requirements as shown in the table below.

For Medicare Plus Blue℠ and BCN Advantage℠ members: We added prior authorization requirements as shown in the table below.

Drug lists

For additional details, see the following drug lists:

• For commercial members: Blue Cross and BCN utilization management medical drug list
• For Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members

These lists are also available by following these steps:

1. Go to ereferrals.bcbsm.com.
2. Click on Blue Cross or BCN.
3. Click on Medical Benefit Drugs.
4. Scroll down and click on the Blue Cross and BCN utilization management medical drug list or the Medicare Plus Blue and BCN Advantage drug list link.

Additional information about these requirements

We communicated these changes previously through provider alerts, which contain additional details. You can view the provider alerts at ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal at availity.com.***

Additional information for Blue Cross commercial groups

For Blue Cross commercial groups, prior authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. To find this list:

1. Go to ereferrals.bcbsm.com.
2. Click on Blue Cross.
3. Click on Medical Benefit Drugs.
4. Scroll down and click on the Group opt in/opt out list link.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and non-Medicare United Auto Workers Retiree Medical Benefits Trust members don't participate in the standard prior authorization program.

Reminder

A prior authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

**May be assigned a unique code in the future.

***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.