Requirements, codes changed for some medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under medical benefits. As part of this effort, we maintain comprehensive lists of requirements for our members.

In October, November and December 2024, we added requirements for some medical benefit drugs. These requirements went into effect on various dates. In addition, one drug was assigned a new HCPCS code.

Changes in requirements

For Blue Cross commercial and BCN commercial members: We added prior authorization requirements for the following drugs:

For Medicare Plus Blue℠ and BCN Advantage℠ members: We added prior authorization requirements for the following drugs:

Code change

The table below shows the HCPCS code change that was effective October 2024 for medical benefit drugs managed by Blue Cross and BCN:

Drug lists

For additional details, see the following drug lists:

• For commercial members: Blue Cross and BCN utilization management medical drug list
• For Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue℠ and BCN Advantage℠ members

These lists are also available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Additional information about these requirements

We communicated these changes previously through provider alerts. Those alerts contain additional details.

You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal at availity.com.**

Additional information for Blue Cross commercial groups

For Blue Cross commercial groups, authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

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.

Reminder

An authorization approval isn’t a guarantee of payment. Health care providers 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.