We’re changing requirements for some medical benefit drugs for Medicare Advantage members

We’re making changes to prior authorization and step therapy requirements for some drugs covered under medical benefits for Medicare Plus Blue℠ and BCN Advantage℠ members.

Prior authorization will be required for two more drugs starting March 1

For dates of service on or after March 1, 2024, the following drugs will require prior authorization:

• Adzynma (ADAMTS13, recombinant-krhn), HCPCS code J3590
• Wainua™ (eplontersen), HCPCS code J3490

Submit prior authorization requests through the NovoLogix^® online tool.

Step therapy requirements will change for some drugs

Providers who request prior authorization for Soliris^®, Ultomiris^® or Zilbrysq^® for the diagnosis of myasthenia gravis will need to show that the member has first tried and failed other drugs, as follows.

⁽¹⁾Refer to the Nov. 13, 2023, provider alert.
⁽²⁾Refer to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members
⁽³⁾Refer to the Dec. 4, 2023, provider alert.

Soliris and Ultomiris already require prior authorization.

When prior authorization is required

These drugs will require prior authorization when they are administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or using the UB04 claim form for a hospital outpatient type of bill 013x

Submit prior authorization requests through the NovoLogix tool

To access NovoLogix, log in to our provider portal (availity.com),** click Payer Spaces in the menu bar and then click the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. 

If you need to request access to Availity^®, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

List of requirements

For a 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.

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

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.