We’ve changed how we manage Entyvio SC, Omvoh SC

On March 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network changed how we manage the following drugs for our Medicare Plus Blue℠ and BCN Advantage℠ members:

• Entyvio^® SC (vedolizumab), HCPCS code J3590
• Omvoh™ SC (mirikizumab-mrkz), HCPCS code J3590

Note: This change doesn’t affect Entyvio IV, HCPCS code J3380, or Omvoh IV, HCPCS code J3590, which will continue to be managed as part of members’ Part B medical benefits. These drugs continue to require prior authorization through the NovoLogix^® web tool.

What changed on March 1

On March 1, Medicare Plus Blue and BCN Advantage members who previously received Entyvio SC or Omvoh SC under the Part B medical benefit were required to continue their treatments under their Part D pharmacy benefits.

We made this change because these therapies can be safely and conveniently self-administered in the home; the Centers for Medicare & Medicaid Services, or CMS, has added these drugs to the Self-Administered Drug Exclusion List: (SAD List).**

As a result:

• These drugs are no longer covered when administered by a doctor or other health care professional under the Part B medical benefit.
• Entyvio SC and Omvoh SC aren’t included in our Medicare Advantage Part D formularies, but providers can request prior authorization for them as exceptions. (See the “How to submit prior authorization requests for Entyvio SC and Omvoh SC” section below.)
• Your patients can obtain these medications at pharmacies that dispense specialty drugs. They can also obtain these drugs from AllianceRx Walgreens Pharmacy through mail order or pickup at a Walgreens retail pharmacy.
• For members who don’t have Part D pharmacy benefits through Blue Cross or BCN, providers need to work with the pharmacy vendor that provides each member’s Part D coverage.

How to submit prior authorization requests for Entyvio SC and Omvoh SC

For members who have Part D pharmacy benefits through Medicare Plus Blue or BCN Advantage, providers need to submit prior authorization requests for Entyvio SC and Omvoh SC as follows: 

• Electronically: Through CoverMyMeds^® or another free ePA tool, such as Surescripts^® or ExpressPAth^®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs for more information.
• By phone: Call 1-800-437-3803 and follow the prompts for medications billed through the pharmacy benefit.
• By fax: 
• For Medicare Plus Blue requests, fax to 1-866-601-4428.
• For BCN Advantage requests, fax to 1-800-459-8027.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

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