Medicare Part B medical specialty drug prior authorization list is changing in February

We're adding the following medications to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician's office, an outpatient facility or a member's home.

For dates of service on or after Feb. 3, 2020, the following medications will require authorization:

  • J3490/C9399 Beovu®
  • J3590 Zolgensma®
  • J3590 Skyrizi™
  • J3490 Spravato™
  • J7170 Hemlibra®
  • J1555 Cuvitru™
  • J1599 Panzyga®
  • Q4074 Ventavis®

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for the following sites of care when you bill the medications as a professional service or as an outpatient facility service and you bill electronically through an 837P transaction or on a professional CMS 1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must obtain authorization prior to administering these medications. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List.

The authorization requirements for these drugs will be reflected on the drug list on Jan. 1, 2020.

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network