Changes to Oncology Value Management program will start April 1

As we previously announced, starting April 1, 2025, oncology pharmacy benefit drugs will be managed through our Oncology Value Management program. Starting April 1, health care providers can submit prior authorization requests for these drugs to OncoHealth, which administers the Oncology Value Management program.

Currently, only oncology medical benefit drugs are managed through the Oncology Value Management program. Adding oncology pharmacy benefit drugs to the program will:

• Affect prior authorization requests for oncology pharmacy benefit drugs for all Blue Cross Blue Shield of Michigan commercial, Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members whose coverage includes a pharmacy benefit
• Enable health care providers to submit a single prior authorization request for a patient’s entire drug regimen — for both oncology medical benefit drugs and oncology pharmacy benefit drugs

When requesting prior authorization, OncoHealth requires that providers submit the entire drug regimen to determine medical necessity. This means providers must include all drugs in the request — those that require prior authorization and those that don’t.

In addition, while reviewing clinical documentation, OncoHealth may add to the request any drugs that weren’t requested, to capture the entire regimen.  

Check member benefits

With the April 1 expansion of the Oncology Value Management program, prior authorization requirements are changing for some commercial members. This is because some members whose employer groups didn’t participate in the Oncology Value Management program prior to April 1 will have requirements under the program for dates of service on or after April 1.

As always, be sure to check benefits for all members before providing services.

Drug lists

By April 1, we’ll update the following drug lists to specify the oncology pharmacy benefit drugs that require prior authorization through OncoHealth.

• For commercial members: Drug lists on the For Providers: Drug Lists page on bcbsm.com
• For Medicare Advantage members: Drug lists on the 2025 Drug Lists for Medicare Members page on bcbsm.com

Where to find the authorization number to include on claims

When submitting claims, include the nine-digit OncoHealth authorization reference number, which is included on all OncoHealth approval letters. To locate the reference number in OncoHealth’s OneUM™ portal:

1. Click on Provider Dashboard in the left navigation.
2. Click on Completed Assignments.
3. Select a completed case to view the case summary.

How to determine billable units for a drug

OncoHealth approves drug regimens based on dose, frequency and duration of the authorization. While billable units aren’t displayed in the OneUM portal, providers can see the approved number of cycles and frequency within the case summary.

To find this information in OncoHealth’s OneUM portal:

1. Click on Provider Dashboard in the left navigation.
2. Click on Completed Assignments.
3. Select a completed case to view the case summary.

Availability of providers in OncoHealth’s OneUM portal

If provider offices are unable to submit a prior authorization request through the OncoHealth OneUM portal because the ordering provider isn’t listed in the portal, email the OncoHealth Client Support Team at clientsupport@oncohealth.us. The team will add the provider.

Courses of treatment that start before April 1 and continue beyond April 1

Members who start receiving oncology pharmacy benefit drugs before April 1 can continue to receive those drugs under their approved authorization until it expires.

Prior authorization is required through OncoHealth only if there’s a change to the treatment plan on or after April 1, or if treatment with the drug extends beyond the authorization end date.

Recorded training

Providers who didn’t attend an OncoHealth provider training session or would like a refresher on the submission process can watch the recorded OncoHealth presentation on our Provider Training site.

To access the recorded training: 

1. Log in to our provider portal at availity.com.**
2. Click on Payer Spaces in the menu bar, and then click the BCBSM and BCN logo.
3. Click on the Provider Training Site tile on the Applications tab.
4. Click on Submit.
5. Search Oncology, and then click OncoHealth presentation.
6. Click on Launch for one of the learning activities.

If you need help with accessing or navigating the site, email ProviderTraining@bcbsm.com.

Additional information

By April 1, we’ll update the Oncology Value Management program through OncoHealth: FAQs for providers document to reflect the information in this alert.

If you have issues while working in OncoHealth’s OneUM portal, email the OncoHealth Client Support Team at clientsupport@oncohealth.us.

As a reminder, prior authorization requests for oncology pharmacy benefit drugs are currently submitted through an electronic prior authorization tool, such as CoverMyMeds^®, and are managed by the Blue Cross and BCN pharmacy departments.

**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.

OncoHealth is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing cancer support services.