Requirements and codes changed for some medical benefit drugs

As part of our efforts to encourage appropriate use of high-cost medications covered under the medical benefit, we recently added requirements for some medical benefit drugs. Also, the Centers for Medicare & Medicaid Services assigned some drugs new HCPCS codes. The changes went into effect on various dates in July, August and September.

Changes in requirements

For Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members, we added prior authorization requirements for the following:

For Medicare Plus Blue℠ and BCN Advantage℠ members, we added prior authorization requirements for the following:

Code changes

The table below shows HCPCS code changes that were effective July 1, 2023, (unless otherwise noted) for medical benefit drugs we manage.

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 on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

More information about these requirements

We communicated these changes previously through provider alerts. Those alerts contain additional details.

You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal (availity.com).***

More information for Blue Cross commercial groups

For Blue Cross commercial groups, 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. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

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

Reminder

An authorization approval isn’t a guarantee of payment. As always, health care providers 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 and electronic data interchange services.

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

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