Jemperli^™ and Zynlonta^™ require prior authorization for dates of service on or after July 26, 2021, for most members

For dates of service on or after July 26, 2021, we're adding prior authorization requirements for the following drugs covered under the medical benefit:

• Jemperli (dostarlimab-gxly), HCPCS codes J3490, J3590, J9999, C9399
• Zynlonta (loncastuximab tesirine-lpyl), HCPCS codes J3490, J3590, J9999, C9399

Submit prior authorization requests through AIM Specialty Health^®.

Prior authorization requirements apply when these drugs are administered in outpatient settings for:

• Blue Cross and Blue Shield of Michigan commercial - Members who have coverage through fully insured groups and members with individual coverage

  Exceptions: The Blue Cross commercial requirements don't apply to members who have coverage through Michigan Education Special Services Association or the Blue Cross and Blue Shield Federal Employee Program^®, or to UAW Retiree Medical Benefits Trust non-Medicare members.

• Medicare Plus Blue^SM members
• Blue Care Network commercial members
• BCN Advantage^SM members

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

• Through the AIM ProviderPortal*
• By calling the AIM Contact Center at 1-844-377-1278

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page* on the AIM website.

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see:

• Blue Cross commercial and BCN commercial:
  • Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members (PDF)
  • Blue Cross and BCN utilization management medical drug list (PDF)
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members (PDF)

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network