Skyrizi^® and Tegsedi^® will be covered under the pharmacy benefit for Blue Cross' PPO and BCN HMO^SM members, effective Oct. 8, 2020

We're changing how we cover Skyrizi and Tegsedi for our Blue Cross' PPO (commercial) and BCN HMO (commercial) members.

Beginning Oct. 8, 2020, Blue Cross' PPO and BCN HMO plans will no longer cover the following medications under the medical benefit. Instead, they'll be covered under the pharmacy benefit.

• Skyrizi (risankizumab-rzaa), HCPCS codes C9399, J3590
• Tegsedi (inotersen), HCPCS codes C9399, J3490

Coverage for these drugs is moving to the pharmacy benefit because the drugs can be safely and conveniently self-administered in the member's home.

These drugs will continue to require prior authorization and are available through pharmacies that dispense specialty drugs, including AllianceRx Walgreens Prime Specialty Pharmacy.

We'll contact any member who is affected by this change and advise them to talk to their doctor about prescribing these medications for purchase from a pharmacy.

Providers who administer these medications to their patients on or after Oct. 8, 2020, will be responsible for the cost.

Are there any changes to the management for these therapies?

There are no changes to the management of these therapies.

• Both Skyrizi and Tegsedi will continue to require prior authorization. For information about submitting prior authorization requests, see "Submitting prior authorization requests" below.
• For Skyrizi, quantity limits continue to apply.
• For Tegsedi, documentation requirements continue to apply.

Submitting prior authorization requests

Providers can submit prior authorization requests for these drugs as follows:

• Electronically: Through CoverMyMeds^® or another free ePA tool, such as Surescripts^® or ExpressPAth^®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF) for more information.
• By phone: Call 1-800-437-3803.
• By fax: Call the Pharmacy Clinical Help Desk at 1-800-437-3803 to obtain the pertinent medication request form, which you can then submit by fax.
  • For Blue Cross’ PPO members: Fax the medication request form to 1-866-601-4425.
  • For BCN HMO members: Fax the medication request form to 1-877-442-3778.
• By written request: Mail a written request to:

  Blue Cross Blue Shield of Michigan
  Attention: Pharmacy Services
  Mail Code 512
  600 E. Lafayette Blvd.
  Detroit, MI 48226-2998

List of requirements

To view requirements for Skyrizi, Tegsedi and other drugs covered under the pharmacy benefit, see the Blue Cross and BCN Prior authorization and step therapy coverage criteria (PDF) document. This document is available from the following pages on the this website.

• Blue Cross Pharmacy Benefit Drugs
• BCN Pharmacy Benefit Drugs

For a list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document.

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