Provider Alerts Archive: 2025

Exdensur SC to require prior authorization for most members starting Jan. 7 and Feb. 2

Boncresa SC, Nufymco and Oziltus SC to require prior authorization for most commercial members starting Jan. 7

Bildyos and Bilprevda to require prior authorization for Medicare Advantage members starting Jan. 2

How to submit appeals related to bundled admissions for BCN Advantage members, starting Dec. 23

We’re updating our forms and documents related to prospective editing (formerly clinical editing)

Authorizations that were issued for Medicare Plus Blue members are being transitioned to NASCO

Reminder: Urgent appeals are treated as member appeals, accepted only when member’s situation is urgent

Waskyra to require prior authorization for most members starting Dec. 22 and Jan. 15

How to submit continued stay and retroactive authorization requests for Medicare Advantage members for post-acute care stays that start before Jan. 5

December and January holiday closures: How to submit authorization requests for inpatient admissions

Reminder: Changes to the inpatient appeal process for Medicare Plus Blue and BCN Advantage, starting Dec. 22

e-referral system out of service for maintenance overnight December 20-21

Jubereq and Osvyrti to require prior authorization for most commercial members starting Dec. 15

E-referral system is mistakenly reporting some Medicare Plus Blue members as “without active eligibility”

Stoboclo, Osenvelt and denosumab-bmwo (unbranded) to have a site-of-care requirement for most commercial members starting March 9

Reminder: Most preferred infliximab, rituximab and ustekinumab products won’t require prior authorization for Medicare Advantage members

Chiropractic services for U-M Premier Care members starting Jan. 1

Itvisma to require prior authorization for most members starting Dec. 8 and Jan. 15

WellSky portal preregistration and other details about changes to the prior authorization process for post-acute care stays for Medicare Advantage members starting Jan. 5

Inspire V device to require prior authorization for commercial members starting Jan. 1

Emrelis, Gazyva and Jobevne to require prior authorization for URMBT members with Blue Cross commercial plans starting March 4

We’re adding requirements for additional medical oncology drugs for most members starting March 4

Medicare Plus Blue claims denied in error for missing prior authorization

Medical benefit drug prior authorization changes for FEP members with Blue Cross commercial plans starting Feb. 1

Duopa, Onapgo and Vyalev will require prior authorization for most commercial members starting March 2

Update: Qivigy and Eydenzelt to require prior authorization for most commercial members starting Oct. 20

Reminder: Submit prior authorization requests for sleep studies to Blue Cross or BCN through the e-referral system for most commercial members

Medicare Plus Blue PPO Provider Manual update coming in January 2026

Tango will manage home health care for our Medicare Advantage members starting March 2

Update: To align with CMS guidelines, Grievance and Appeals will manage the acute inpatient admission appeal process for Medicare Advantage members, starting Dec. 22

Global referrals aren’t required for Michigan State University employee health plan

Nov. 27-28 holiday closure: How to submit authorization requests for inpatient admissions

Delayed: Submit musculoskeletal prior authorization requests for FEP members to TurningPoint

Provider consultant inquiry mailbox to resume regular operations on Nov. 24 for providers in East, Mid and Southeast regions

Update: We’re changing how we manage Simponi Aria for most commercial members, starting Feb. 1

Existing and submitted authorizations aren’t affected by the updated diagnosis code for multiple sclerosis

Update: We are changing how we manage Entyvio for most PPO, HMO commercial members, starting Jan. 1

e-referral system out of service for maintenance overnight November 15-16

Learn more about changes to prior authorization process for post-acute care starting Jan. 5

Register for a Nov. 11, 13 or 19 Q&A session about prior authorization process changes for in-lab sleep studies for most commercial members

2026 Medicare pharmacy updates

Changes to prior authorization requirements for select services managed by Blue Cross and BCN starting Nov. 2

We’re changing how we manage Simponi Aria for most commercial members, starting Feb. 1

Bkemv to have a site-of-care requirement for most commercial members starting Feb. 1

HCPCS replacement codes established, effective Oct. 1, 2025

We’re making changes to our acute inpatient admission appeal process to align with CMS guidelines

New fields added to e-referral inpatient authorizations

Use the Medical and Pharmacy Drug PA Portal to submit prior authorization requests for pharmacy benefit drugs

Aflibercept-yszy and Yimmugo to require prior authorization for Medicare Advantage members starting Oct. 27

Updated: New Provider Prior Authorizations website launches Oct. 22

Update: Qivigy and Eydenzelt to require prior authorization for most commercial members starting Oct. 20

Enoby SC and Xtrenbo SC to require prior authorization for most commercial members starting Oct. 20

Changes to step therapy requirements for some medical benefit drugs for Medicare Advantage members

Training and FAQ now available for prior authorization process changes for in-lab sleep studies managed by Blue Cross and BCN

The average length of stay at most skilled nursing facilities has increased

We’re implementing point-of-sale edit for concurrent use of opioids, benzodiazepines beginning mid-October 2025

Update: Changes to prior authorization requirements for post-acute care services for Medicare Advantage members

e-referral system out of service for maintenance overnight October 18-19

Provider consultant inquiry mailbox temporarily closed, affects providers in East, Mid and Southeast regions

New BCN Advantage inpatient facility admissions peer-to-peer review process, starting Jan. 1

Update: Changes to preferred drug designations and other requirements for Medicare Advantage members, starting Nov. 1 and Jan. 1

We’ll use updated ABA supplemental policy starting Jan. 1

Changes to preferred drug designations under the medical benefit for most members, starting Jan. 1

Changes to our gold carding program for inpatient stays

Update: Fensolvi, Triptodur to have requirements for most commercial members, starting Jan. 1

Iluvien, Retisert to require prior authorization, step therapy requirements for most commercial members, starting Jan. 1

Update: Additional drugs to require prior authorization for Blue Cross commercial URMBT members starting Dec. 31

Beginning Jan. 1, Blue Cross commercial self-funded groups will move to Exclusive Specialty Network

Submit musculoskeletal prior authorization requests for FEP members to TurningPoint starting Jan. 1

Complete clinical documentation is required for Medicare Advantage post-acute care stay requests

Changes to prior authorization requirements for post-acute care and home health care services for Medicare Advantage member

Changes to prior authorization requirements for select services managed by Blue Cross and BCN starting Sept. 28

We are changing how we manage Entyvio for most PPO, HMO commercial members, starting Jan. 1

We’re changing how we cover continuous glucose monitor products for commercial members, starting Jan. 1, 2026

Akynzeo, Cinvanti, Focinvez and Sustol to require prior authorization for most members starting Jan. 1

Aukelso and Bosaya to require prior authorization for most commercial members starting Sept. 29

Submit prior authorization requests for FEP members through the e-referral system starting Jan. 1

Updated Carelon clinical guidelines for various services

We’re no longer capturing clinical outcomes through Audaire Health for select medical benefit drugs for commercial members

Starting Jan. 1, 2026, we’ll change how we cover some drugs on our drug lists

Starting Jan. 1, we’ll change how we cover Rinvoq, Rinvoq LQ and Skyrizi on our Custom Select Drug List

Updated TurningPoint medical policies for musculoskeletal and pain management procedures

Training opportunities for in-lab sleep studies managed by Blue Cross and BCN

Learn more about prior authorization process changes for in-lab sleep studies for commercial members

e-referral system out of service for maintenance overnight September 20-21

Niktimvo to require prior authorization for Blue Cross commercial URMBT members starting Dec. 10

Leqembi IQLIK to require prior authorization for Medicare Advantage members starting Oct. 1

Bildyos SC and Bilprevda SC to require prior authorization for most commercial members starting Sept. 15

Update: Osenvelt and Stoboclo will be the preferred denosumab biosimilar products for most commercial members starting Dec. 15

New requirements for billing Part B compounded medications used in implantable infusion pumps starting Sept. 1

Update: Stoboclo and Osenvelt to be preferred denosumab products for Medicare Advantage members starting Dec. 15

Anktiva, Herceptin Hylecta and Onivyde will have step therapy requirements for most members starting Dec. 1

Datroway to require prior authorization for most members starting Dec. 1

Changes to prior authorization requirements for select services managed by BCN starting Aug. 24

Sept. 1 holiday closure: How to submit authorization requests for inpatient admissions

Papzimeos to require prior authorization for most commercial members starting Aug. 28

Additional drugs to require prior authorization for Blue Cross commercial URMBT members starting Nov. 12

Select the requesting provider when submitting prior authorization requests in the Medical and Pharmacy Drug PA Portal

e-referral system out of service for maintenance overnight August 16-17, 30-31

Additional drugs to require prior authorization for Medicare Advantage members starting Oct. 1

Starting Sept. 1, we’re replacing Humira with biosimilar drugs for most Medicare Advantage members

Changes to prior authorization requirements for select services managed by Blue Cross and BCN starting July 27

For medical procedures managed by BCN Utilization Management, submit prior authorization requests only for established procedure codes

Update: How to access the Medical and Pharmacy Drug PA Portal to submit prior authorization requests for commercial members

Bkemv will be the preferred eculizumab product for commercial members starting Oct. 12

EviCore category assignments and practitioner performance summaries for PTs and OTs will be available Aug. 1

e-referral system out of service for maintenance overnight July 19-20

Gammagard Liquid ERC to have requirements for most commercial members starting July 14

Additional drugs to have requirements for Blue Cross commercial URMBT members starting Oct. 8

Update: Medicare Advantage prior authorization requests submitted through NovoLogix must be submitted through a different application starting Aug. 1

Changes to prior authorization requirements for additional services managed by BCN starting June 29

Submit prior authorization requests for FEP members through the e-referral system starting Oct. 6

July 4 holiday closure: How to submit authorization requests for inpatient admissions

Reminder: Submit prior authorization requests for non-emergency air ambulance flights to Alacura before takeoff

e-referral system out of service for maintenance overnight June 21-22

Submit clinical documentation for most drugs through the Medical and Pharmacy Drug PA Portal for commercial members

June 19 holiday closure: How to submit authorization requests for inpatient admissions

Update to InterQual Connect question in the e-referral system for varicose vein treatment

Register now for June 17 webinar on prior authorization best practices with Carelon

Inpatient admissions for musculoskeletal procedures managed by TurningPoint

Starjemza to require prior authorization for most commercial members starting June 12

Gamifant to require prior authorization for most members starting Sept. 3

Answers to questions about changes to requirements for pain management procedures for our Medicare Advantage members

Changes to prior authorization for select services managed by BCN starting June 2 and June 29

We’re changing how we manage self-administered hemophilia products for most Blue Cross, BCN commercial members, starting Sept. 1

Starting Sept. 1, we’ll change how we pay for certain medications for most Blue Cross, BCN commercial members

Yesintek to have a site-of-care requirement for most commercial members starting Sept. 1

Ignore questionnaire prompts when requesting organization determinations for pain management procedures for BCN Advantage members

New and updated requirements for some medical benefit drugs for Blue Cross commercial URMBT members starting Aug. 20

We’re adding requirements for additional medical oncology drugs for most members starting Aug. 20

Opuviz will require prior authorization for Medicare Advantage members starting Aug. 1

May 26 holiday closure: How to submit authorization requests for inpatient admissions

e-referral system out of service for maintenance overnight May 17-18, May 30-June 1

Imaavy IV and Zevaskyn to require prior authorization for most members

Register for a May 6 or May 8 Q&A session about the Medical and Pharmacy Drug PA Portal for most commercial members

Starting June 1, we’re replacing Stelara with biosimilar drugs for most Medicare Advantage members

Additional drugs to require prior authorization for Blue Cross commercial URMBT members starting July 30

Qfitlia to require prior authorization for Medicare Advantage members starting June 1

Provider websites unavailable overnight April 25-26

e-referral system out of service for maintenance overnight April 19-20, 25-26

Best practices for submitting prior authorization requests with InterQual Connect questions through the e-referral system

April 18 holiday closure: How to submit authorization requests for inpatient admissions

Update: Selarsdi to require prior authorization for most members

Qfitlia SC and some denosumab products to require prior authorization for most commercial members for dates of service on or after April 11

Reminder: Prior authorization won’t be required for pain management procedures for Medicare Advantage members starting May 1

Medicare Advantage prior authorization requests submitted through NovoLogix must be submitted through a different application starting July 1

Update: Commercial prior authorization requests submitted through NovoLogix must be submitted through a different application starting April 21

Issue resolved: Providers may experience delays when submitting prior authorization requests to Carelon

Changes to prior authorization for select services managed by Blue Cross and BCN starting March 23

Complete the Continuity of Care Guideline in the e-referral system for some Medicare Advantage members starting April 3

Step therapy required for Keytruda and Opdivo for nasopharyngeal cancer for most members starting June 18

Update: Omlyclo and omalizumab-igec require prior authorization for most commercial members for dates of service on or after March 27

Professional reimbursement increased for select procedures performed in ambulatory surgical facilities

Encelto to require prior authorization for most members

e-referral system out of service for maintenance overnight March 15-16

Denosumab-dssb SC, Osenvelt SC and Stoboclo SC to require prior authorization

How we communicate changes to medical policies for medical benefit drugs that require prior authorization for commercial members

Changes to the management of oncology medical benefit drugs starting June 1

Changes to the Oncology Value Management program starting April 1

Update: Tyenne will be preferred tocilizumab biosimilar product for most commercial members, starting June 1

Alyglo, Amtagvi and Loqtorzi to have requirements for Blue Cross commercial URMBT members starting June 1

Xbryk and Ospomyv to require prior authorization for most commercial members starting Feb. 28

Claims for Medicare Advantage PPO individual members on NASCO system denying as no authorization on file

Questionnaire changes in the e-referral system starting Feb. 23

We’ll use updated ABA supplemental policy starting April 22

Update: Step therapy won’t be required for Darzalex Faspro

How to obtain CGM products for commercial and Medicare Advantage members

Rebyota and Ryoncil will have additional requirements for most commercial members starting March 31

Trazimera to be preferred trastuzumab product for Medicare Advantage members starting May 12

Avtozma to require prior authorization for most commercial members starting Feb. 20

Ahzantive, Enzeevu, Epysqli and Pavblu to require prior authorization for Medicare Advantage members starting May 1

e-referral system out of service for maintenance overnight February 15-16

Step therapy requirements added for Entyvio, Rystiggo, Vabysmo and Vyvgart and for Medicare Advantage members starting May 1

Finding which procedure codes require prior authorization by TurningPoint

Update: Piasky and Tremfya to have a site-of-care requirement for most commercial members starting June 1

Update: Prior authorization changes for blepharoplasty and percutaneous left atrial appendage closure devices starting Feb. 2

Requesting retroactive authorizations if Carelon displays an incorrect coverage end date for Medicare Plus Blue

We’ll no longer require prior authorization for pain management procedures for Medicare Advantage members

Some continuous glucose monitoring products available through participating network pharmacies for commercial members

Evenity to have additional step therapy requirements for Medicare Advantage members starting May 1

New Acute inpatient hospital assessment form for commercial and Medicare Advantage members

We’re changing how we manage Stelara and Stelara biosimilar therapies for most commercial members, starting April 1 and May 1

Continue to answer InterQual Connect questions in the e-referral system while we investigate technical issues

Updated: Simlandi preferred adalimumab product for Blue Cross, BCN commercial members

New Blue Elect Plus HRA POS

Additional drugs to have requirements for Blue Cross commercial URMBT members starting April 16

EviCore category assignments and practitioner performance summaries for PTs and OTs will be available Feb. 3

Submit reconsideration requests for commercial members through the TurningPoint provider portal

Jan. 20 holiday closure: How to submit authorization requests for inpatient admissions

How to enter subscriber/enrollee IDs when submitting electronic prior authorization requests for pharmacy benefit drugs

e-referral system out of service for maintenance overnight January 18-19

Alhemo to require prior authorization for most commercial members starting Jan. 16

Finding which procedure codes require authorization by Carelon or EviCore

Commercial prior authorization requests submitted through NovoLogix must be submitted through a different application starting April 1

Ryoncil to require prior authorization for most members