Cabenuva to have requirements for most commercial members, starting May 1

For dates of service on or after May 1, 2024, we’re adding prior authorization and site-of-care requirements for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under the medical benefit:

• Cabenuva (cabotegravir, rilpivirine), HCPCS code J0741

For members who start a new course of treatment on or after May 1, providers will need to submit a prior authorization request.

How to submit prior authorization requests

Submit prior authorization requests through the NovoLogix^® online tool. The tool offers real-time status checks and immediate approvals for certain medications.

To access NovoLogix:

1. Log in to our provider portal through Availity^® at availity.com.**
2. Click Payer Spaces in the menu bar, then click the BCBSM and BCN logo.
3. Access the links to the NovoLogix tools in the Applications tab.

Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.

The NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests for this drug. If the request meets clinical criteria for the drug and is for one of the following sites of care, it’ll be approved automatically:

• Doctor or other health care provider’s office
• Ambulatory infusion center
• The member’s home, from a home infusion therapy provider

Additional information or documentation may be required for requests to administer Cabenuva in an outpatient hospital setting.

What about members who start a course of treatment before May 1?

For members who start a course of treatment with Cabenuva before May 1, 2024, providers won’t need to submit prior authorization requests for dates of service from May 1 through Nov. 1, 2024. We’ll automatically approve authorizations through Nov. 1 and these members can continue receiving the drug in the original site of care during that time.

For dates of service on or after Nov. 2, 2024, for these members, providers will need to submit prior authorization requests. These requests will be subject to the site-of-care requirement outlined above.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial groups, this prior authorization requirement applies only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don’t participate in the standard prior authorization program.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ll update this list prior to the effective date.

You can access these lists and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior 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.

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.

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.