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November 2023

Beyfortus to have quantity limits for commercial members, starting Jan. 1

Starting Jan. 1, 2024, Beyfortus™ (nirsevimab-alip), procedure codes *90380 and *90381, will have quantity limits when billed under the pharmacy benefit. There won’t be quantity limits when Beyfortus is billed under the medical benefit.

Note: For the administration of Beyfortus, use procedure codes *96380 and *96381.

Administration site and coverage details

Beyfortus is covered as follows.

Administration site

How it’s covered

Health care provider’s office

Under the medical benefit, with no quantity limits

Retail pharmacy when the member has pharmacy benefits through Blue Cross Blue Shield of Michigan or Blue Care Network

Under the pharmacy benefit

Quantity limits will apply

Retail pharmacy when both of the following are true:

  • The member doesn’t have pharmacy benefits through Blue Cross or BCN.
  • The pharmacy participates in the Blue Cross Vaccine Affiliation Program.

Under the medical benefit, with no quantity limits

Blue Cross commercial groups that may have cost sharing or may not have vaccine coverage

For members who have coverage through Blue Cross Blue Shield of Michigan commercial groups that are exempt from the Patient Protection and Affordable Care Act, members may have cost sharing or they may not have vaccine coverage.

Here’s how to check member eligibility and benefits for vaccines:

  1. Log in to our provider portal (availity.com).**
  2. Click on Patient Registration in the menu bar and then click on Eligibility and Benefits Inquiry.
  3. Enter the payer information and complete the fields in the Provider Information section.
  4. Complete the Patient Information section and click on Search.
  5. Select the row for the appropriate member.
  6. In the Service Information section, enter Immunizations in the Benefit/Service Type field.
  7. Click on Submit.
  8. Do one of the following:

If…

Then…

There is a Benefit Explainer button near the top of the screen
  1. Click on the Benefit Explainer button.
    2. Tip: If Benefit Explainer doesn’t open, you’ll need to allow
    Availity® Essentials to open popups.
  2. In Benefit Explainer, click on the Search button.
  3. Press CTRL+F.
  4. Search on Preventive Immunizations.

There isn’t a Benefit Explainer button near the top of the screen
  1. Press CTRL+F.
  2. Search on Immunizations.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

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.

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