Medicare Part B medical specialty drug prior authorization list changing July 22, 2019

We're making changes to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior authorization drug list, as follows:

• For dates of service on or after July 22, 2019, Darzalex^® (J9145) will require prior authorization.
• Effective immediately, Myozyme^® (J0220) is removed from the prior authorization list because it is no longer available in the U.S. market.

Here's some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO

For Medicare Plus Blue, we require prior authorization for Darzalex when you bill 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 BCN Advantage, we require prior authorization for Darzalex when you bill it 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 Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through Novologix.

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