Additional medical benefit specialty drugs will require prior authorization for Blue Cross' PPO and BCN HMOSM members

We're expanding the prior authorization program for specialty drugs covered under the medical benefit to include the following drugs for Blue Cross' PPO (commercial) and BCN HMO (commercial) members:

  • Beovu® (brolucizumab, HCPCS code J3490/J3590)
  • Macugen® (pegaptanib, HCPCS code J2503)
  • Scenesse® (afamelanotide, HCPCS code J3490)

For BCN HMO members:

  • We'll require authorization for Beovu and Scenesse for members who begin therapy on or after Nov. 15, 2019.
  • We'll require authorization for Macugen for members who begin therapy on or after Jan. 1, 2020.

For Blue Cross' PPO members:

  • We'll require authorization for Beovu, Macugen and Scenesse for members who begin therapy on or after Jan. 1, 2020.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by Medicare Plus BlueSM PPO, BCN AdvantageSM or the Federal Employee Program® Service Benefit Plan; however, Medicare Plus Blue and BCN AdvantageSM have required authorization for Macugen since 2017 and will require authorization for Beovu starting on Feb. 3, 2020.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on this website:

We'll update the requirements list for the drugs listed above prior to the date on which each drug will require authorization.

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