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November 2023

Some diabetes drugs to require prior authorization for Blue Cross and BCN members, starting Jan. 1

Beginning Jan. 1, 2024, the presence of prior pharmacy claims for insulin alone will no longer qualify Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members for coverage of the medications in the table listed below. We’ll require a prior authorization to confirm that the medications listed below are being used for Type 2 diabetes for members who don’t have a supporting prescription or medical record with a diabetes diagnosis.

The full-coverage requirements are listed in the table below.

Brand-name medication

FDA-approved indication

Coverage requirements starting Jan. 1

Bydureon®
Byetta®
Mounjaro®
Ozempic®

Rybelsus®
Trulicity®
Victoza®

 

 

 

 

 

 

Type 2 diabetes

Coverage without prior authorization will require diagnosis of Type 2 diabetes verified by one of the following:

  • Trial of one generic or preferred medication for the treatment of Type 2 diabetes within the prior 12-month period, except for metformin, GLP-1 receptor agonist, or insulin**
  • Diagnosis code for Type 2 diabetes identified in medical claim history within the prior 24-month period

If either coverage criteria outlined above isn’t fulfilled, you must submit a prior authorization to confirm that your patient has a diagnosis of Type 2 diabetes for coverage.

**Effective Jan. 1, 2024, previous trial of only insulin will no longer qualify members for coverage without prior authorization if they don’t have a medical diagnosis of Type 2 diabetes.

For more information on how to submit an authorization electronically:

  1. Go to ereferrals.bcbsm.com.
  2. Select Blue Cross for PPO members or BCN for HMO members.
  3. Click on Pharmacy Benefit Drugs on the left.
  4. Scroll down to How to submit an electronic prior authorization, or ePA, request

A complete list of included drugs and coverage requirements for all drug lists is available at bcbsm.com/druglists.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2022 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.