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How to submit appeals related to bundled admissions for BCN Advantage members, starting Dec. 23

We’re updating our forms and documents related to prospective editing (formerly clinical editing)

Authorizations that were issued for Medicare Plus Blue members are being transitioned to NASCO

Reminder: Urgent appeals are treated as member appeals, accepted only when member’s situation is urgent

Waskyra to require prior authorization for most members starting Dec. 22 and Jan. 15

How to submit continued stay and retroactive authorization requests for Medicare Advantage members for post-acute care stays that start before Jan. 5

December and January holiday closures: How to submit authorization requests for inpatient admissions

Reminder: Changes to the inpatient appeal process for Medicare Plus Blue and BCN Advantage, starting Dec. 22

e-referral system out of service for maintenance overnight December 20-21

Jubereq and Osvyrti to require prior authorization for most commercial members starting Dec. 15

E-referral system is mistakenly reporting some Medicare Plus Blue members as “without active eligibility”

Stoboclo, Osenvelt and denosumab-bmwo (unbranded) to have a site-of-care requirement for most commercial members starting March 9

Reminder: Most preferred infliximab, rituximab and ustekinumab products won’t require prior authorization for Medicare Advantage members

Chiropractic services for U-M Premier Care members starting Jan. 1

Itvisma to require prior authorization for most members starting Dec. 8 and Jan. 15

WellSky portal preregistration and other details about changes to the prior authorization process for post-acute care stays for Medicare Advantage members starting Jan. 5

Inspire V device to require prior authorization for commercial members starting Jan. 1

Emrelis, Gazyva and Jobevne to require prior authorization for URMBT members with Blue Cross commercial plans starting March 4

We’re adding requirements for additional medical oncology drugs for most members starting March 4

Medicare Plus Blue claims denied in error for missing prior authorization

Medical benefit drug prior authorization changes for FEP members with Blue Cross commercial plans starting Feb. 1

Duopa, Onapgo and Vyalev will require prior authorization for most commercial members starting March 2

Update: Qivigy and Eydenzelt to require prior authorization for most commercial members starting Oct. 20

Reminder: Submit prior authorization requests for sleep studies to Blue Cross or BCN through the e-referral system for most commercial members

Medicare Plus Blue PPO Provider Manual update coming in January 2026

Tango will manage home health care for our Medicare Advantage members starting March 2

Update: To align with CMS guidelines, Grievance and Appeals will manage the acute inpatient admission appeal process for Medicare Advantage members, starting Dec. 22

Global referrals aren’t required for Michigan State University employee health plan

Nov. 27-28 holiday closure: How to submit authorization requests for inpatient admissions

Delayed: Submit musculoskeletal prior authorization requests for FEP members to TurningPoint

Provider consultant inquiry mailbox to resume regular operations on Nov. 24 for providers in East, Mid and Southeast regions

Update: We’re changing how we manage Simponi Aria for most commercial members, starting Feb. 1

Existing and submitted authorizations aren’t affected by the updated diagnosis code for multiple sclerosis

Update: We are changing how we manage Entyvio for most PPO, HMO commercial members, starting Jan. 1

e-referral system out of service for maintenance overnight November 15-16

Learn more about changes to prior authorization process for post-acute care starting Jan. 5

Register for a Nov. 11, 13 or 19 Q&A session about prior authorization process changes for in-lab sleep studies for most commercial members

2026 Medicare pharmacy updates

Changes to prior authorization requirements for select services managed by Blue Cross and BCN starting Nov. 2

We’re changing how we manage Simponi Aria for most commercial members, starting Feb. 1

Bkemv to have a site-of-care requirement for most commercial members starting Feb. 1

HCPCS replacement codes established, effective Oct. 1, 2025

We’re making changes to our acute inpatient admission appeal process to align with CMS guidelines

New fields added to e-referral inpatient authorizations

Use the Medical and Pharmacy Drug PA Portal to submit prior authorization requests for pharmacy benefit drugs

Aflibercept-yszy and Yimmugo to require prior authorization for Medicare Advantage members starting Oct. 27

Updated: New Provider Prior Authorizations website launches Oct. 22

Update: Qivigy and Eydenzelt to require prior authorization for most commercial members starting Oct. 20

Enoby SC and Xtrenbo SC to require prior authorization for most commercial members starting Oct. 20

Changes to step therapy requirements for some medical benefit drugs for Medicare Advantage members

Training and FAQ now available for prior authorization process changes for in-lab sleep studies managed by Blue Cross and BCN

The average length of stay at most skilled nursing facilities has increased

We’re implementing point-of-sale edit for concurrent use of opioids, benzodiazepines beginning mid-October 2025

Update: Changes to prior authorization requirements for post-acute care services for Medicare Advantage members

e-referral system out of service for maintenance overnight October 18-19

Provider consultant inquiry mailbox temporarily closed, affects providers in East, Mid and Southeast regions

New BCN Advantage inpatient facility admissions peer-to-peer review process, starting Jan. 1

Update: Changes to preferred drug designations and other requirements for Medicare Advantage members, starting Nov. 1 and Jan. 1

We’ll use updated ABA supplemental policy starting Jan. 1

Changes to preferred drug designations under the medical benefit for most members, starting Jan. 1

Changes to our gold carding program for inpatient stays

Update: Fensolvi, Triptodur to have requirements for most commercial members, starting Jan. 1

Iluvien, Retisert to require prior authorization, step therapy requirements for most commercial members, starting Jan. 1

Update: Additional drugs to require prior authorization for Blue Cross commercial URMBT members starting Dec. 31

Beginning Jan. 1, Blue Cross commercial self-funded groups will move to Exclusive Specialty Network

Submit musculoskeletal prior authorization requests for FEP members to TurningPoint starting Jan. 1

Complete clinical documentation is required for Medicare Advantage post-acute care stay requests

Changes to prior authorization requirements for post-acute care and home health care services for Medicare Advantage member

Changes to prior authorization requirements for select services managed by Blue Cross and BCN starting Sept. 28

We are changing how we manage Entyvio for most PPO, HMO commercial members, starting Jan. 1

We’re changing how we cover continuous glucose monitor products for commercial members, starting Jan. 1, 2026

Akynzeo, Cinvanti, Focinvez and Sustol to require prior authorization for most members starting Jan. 1

Aukelso and Bosaya to require prior authorization for most commercial members starting Sept. 29

Submit prior authorization requests for FEP members through the e-referral system starting Jan. 1

Updated Carelon clinical guidelines for various services

We’re no longer capturing clinical outcomes through Audaire Health for select medical benefit drugs for commercial members

Starting Jan. 1, 2026, we’ll change how we cover some drugs on our drug lists

Starting Jan. 1, we’ll change how we cover Rinvoq, Rinvoq LQ and Skyrizi on our Custom Select Drug List

Updated TurningPoint medical policies for musculoskeletal and pain management procedures

Training opportunities for in-lab sleep studies managed by Blue Cross and BCN

Learn more about prior authorization process changes for in-lab sleep studies for commercial members

e-referral system out of service for maintenance overnight September 20-21

Niktimvo to require prior authorization for Blue Cross commercial URMBT members starting Dec. 10

Leqembi IQLIK to require prior authorization for Medicare Advantage members starting Oct. 1

Bildyos SC and Bilprevda SC to require prior authorization for most commercial members starting Sept. 15

Update: Osenvelt and Stoboclo will be the preferred denosumab biosimilar products for most commercial members starting Dec. 15

New requirements for billing Part B compounded medications used in implantable infusion pumps starting Sept. 1

Update: Stoboclo and Osenvelt to be preferred denosumab products for Medicare Advantage members starting Dec. 15

Anktiva, Herceptin Hylecta and Onivyde will have step therapy requirements for most members starting Dec. 1

Datroway to require prior authorization for most members starting Dec. 1

Changes to prior authorization requirements for select services managed by BCN starting Aug. 24

Sept. 1 holiday closure: How to submit authorization requests for inpatient admissions

Papzimeos to require prior authorization for most commercial members starting Aug. 28

Additional drugs to require prior authorization for Blue Cross commercial URMBT members starting Nov. 12

Select the requesting provider when submitting prior authorization requests in the Medical and Pharmacy Drug PA Portal

e-referral system out of service for maintenance overnight August 16-17, 30-31

Additional drugs to require prior authorization for Medicare Advantage members starting Oct. 1

Starting Sept. 1, we’re replacing Humira with biosimilar drugs for most Medicare Advantage members

Changes to prior authorization requirements for select services managed by Blue Cross and BCN starting July 27

For medical procedures managed by BCN Utilization Management, submit prior authorization requests only for established procedure codes

Update: How to access the Medical and Pharmacy Drug PA Portal to submit prior authorization requests for commercial members

Bkemv will be the preferred eculizumab product for commercial members starting Oct. 12

EviCore category assignments and practitioner performance summaries for PTs and OTs will be available Aug. 1

e-referral system out of service for maintenance overnight July 19-20

Gammagard Liquid ERC to have requirements for most commercial members starting July 14

Additional drugs to have requirements for Blue Cross commercial URMBT members starting Oct. 8