Zynyz to require prior authorization for most members, starting Dec. 10

For dates of service on or after Dec. 10, 2023, Zynyz™ (retifanlimab-dlwr), HCPCS code J9345, will require prior authorization through Carelon Medical Benefits Management (formerly known as AIM Specialty Health^®).

The drug is covered under the members’ medical benefits, not their pharmacy benefits.

Prior authorization requirements apply when the drug is administered in outpatient settings for:

• Blue Cross Blue Shield of Michigan commercial
• All fully insured members (group and individual)
• Members who have coverage through self-funded groups that have opted in to the Carelon medical oncology program. (Although UAW Retiree Medical Benefits Trust non-Medicare plans have opted in to this program, these requirements may not apply; refer to their medical oncology drug list, which is linked below.)
  Note: This requirement doesn’t apply to members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.

• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

How to submit authorization requests

Submit authorization requests to Carelon using one of the following methods:

• Through the Carelon ProviderPortal, which you can access by doing one of the following:
• Logging in to our provider portal (availity.com),** clicking on Payer Spaces and then clicking on the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space where you’ll click on the Carelon ProviderPortal tile.
  Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.
• Logging in directly to the Carelon ProviderPortal at providerportal.com.**

• By calling the Carelon Contact Center at 1-844-377-1278

More about the prior authorization requirements

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

• Blue Cross commercial and BCN commercial:
• Medical oncology prior authorization list for Blue Cross and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date.
As a reminder, authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

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 doesn’t own or control this website.