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November 2023

Changes coming to preferred drug designations under medical benefit for most commercial members

For dates of service on or after Jan. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to preferred drug designations for some products. In addition, providers will need to submit prior authorization requests through different systems for some preferred and nonpreferred drugs.

These changes will affect:

  • Most Blue Cross commercial members
    • Exception: These changes don’t apply to UAW Retiree Medical Benefits Trust non-Medicare members or Blue Cross and Blue Shield Federal Employee Program® members.
  • All BCN commercial members

Changes to preferred drug designations

We’re changing preferred drug designations as shown in the following table. Changes are in bold text.

Product

Preferred drugs

Before Jan. 1, 2024

On or after Jan. 1, 2024

Bevacizumab
  • Mvasi®
  • Zirabev®

Mvasi only

Pegfilgrastim
  • Fulphila
  • Neulasta®, Neulasta® OnPro®
  • Ziextenzo®
  • Neulasta, Neulasta OnPro
  • Nyvepria®

Rituximab
  • Riabni™
  • Ruxience®
  • Ruxience
  • Truxima®

Trastuzumab
  • Kanjinti®
  • Trazimera®
  • Kanjinti
  • Ogivri®

How existing prior authorizations are affected by these changes

Existing prior authorizations are affected as follows:

  • For bevacizumab, rituximab and trastuzumab products, the member can continue taking a drug that will be designated as nonpreferred after Jan. 1 until their existing authorization expires. However, we encourage health care providers to begin using products that will be designated as preferred starting Jan. 1, 2024.
  • For pegfilgrastim products, active authorizations for Fulphila and Ziextenzo will end Dec. 31, 2023. Providers will need to transition members who are currently taking Fulphila or Ziextenzo to a preferred drug for dates of service on or after Jan. 1, 2024.

Changes to prior authorization processes

The following table outlines prior authorization requirements for the drugs listed above for dates of service on or after Jan. 1, 2024.

To determine which Blue Cross commercial groups have opted in to the Carelon medical oncology program, see the Carelon medical oncology prior authorization program opt-in list for Blue Cross commercial self-funded groups.

Lines of business

Changes to requirements
  • BCN commercial members
  • Blue Cross commercial members whose groups participate in the Carelon medical oncology program
  • Preferred drugs will require prior authorization through Carelon Medical Benefits Management.

    • Exception: Rituximab preferred drugs won’t require prior authorization.

  • Nonpreferred drugs will require prior authorization through NovoLogix. 

Blue Cross commercial members whose groups don’t participate in the Carelon medical oncology program
  • Preferred products won’t require prior authorization.
  • Nonpreferred products will require prior authorization through NovoLogix.  

Additional information

For additional information on requirements related to drugs covered under the medical benefit, refer to the following drug lists:

For additional information about medical benefit drugs, see the following pages of our ereferrals.bcbsm.com website:

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.