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

We updated this message on March 16, 2020, to remove J3590 Avsola from the list of drugs that will require authorization starting June 15. Avsola won't require prior authorization.

We're adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM PPO and BCN AdvantageSM members. The specialty medications on this list are administered by a healthcare professional in a provider office, at the member's home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

For dates of service on or after June 15, 2020, the following medications will require prior authorization through NovoLogix®:

  • J1428 Exondys 51®
  • J3490 Vyondys 53™
  • J3490 Givlaari®
  • J3590 Tepezza™
  • J3590 Vyepti™

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient sites of care when you bill these medications as a professional service or as an outpatient facility service:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

For these drugs, submit authorization requests through the NovoLogix online tool. 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 Access 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 Access 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 for Medicare Plus Blue PPO and BCN Advantage members.

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network