Additional medical benefit specialty drugs will have authorization and site of care requirements for Blue Cross' PPO and BCN HMOSM members in January and February 2020

The prior authorization and site of care program for specialty drugs covered under the medical benefit is expanding to include the following drugs for Blue Cross' PPO (commercial) and BCN HMO (commercial) members:

  • Adakveo® (crizanlizumab-tmca, HCPCS code J3590)
  • Vyondys 53™ (golodirsen, HCPCS code J3490)

For Blue Cross' PPO members:
  • We'll require authorization for Adakveo and Vyondys 53 for members who begin therapy on or after Feb. 1, 2020.

For BCN HMO members:

  • We'll require authorization for Adakveo and Vyondys 53 for members who begin therapy on or after Jan. 2, 2020.
  • Adakveo and Vyondys 53 will be added to the site of care program for BCN HMO members effective Jan. 2, 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.

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 each drug shown above prior to the date of the change for that drug.

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