Medicare Part B medical specialty drug prior authorization lists changing in June 2019

We're making changes to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list. The following medications are being added to the list.

Medicare Plus Blue PPO

For dates of service on or after June 3, 2019, the following medications will require prior authorization:

  • J3590 Ultomiris™
  • J9999 (C9044) Libtayo®
  • J3245 Ilumya™
  • Q510X Ixifi™
  • J3590/J9999 Elzonris™
  • J3397 Mepsevii™
  • J3490 Tegsedi™
  • J9173 Imfinzi®
  • J3304 Zilretta®

For Medicare Plus Blue, we require prior authorization for these medications when you bill them electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For dates of service on or after June 3, 2019, the following medications will require prior authorization:

  • J3590 Ultomiris™
  • J9999 (C9044) Libtayo®
  • J3245 Ilumya™
  • Q510X Ixifi™
  • J3590/J9999 Elzonris™
  • J3397 Mepsevii™
  • J3490 Tegsedi™
  • J9173 Imfinzi®
  • J3304 Zilretta®

For BCN Advantage, we require prior authorization for these medications when you bill them as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through Novologix.
  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.

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