Medical Benefit Drugs: How to determine requirements for oncology medical benefit drugs

The steps required to determine utilization management requirements vary.

Verify that the member is eligible and has the appropriate benefits.
Requirements vary depending on the member’s plan:

Plan	What to do	Additional information
Blue Cross Blue Shield of Michigan commercial	For most members: Determine whether the drug requires prior authorization through OncoHealth by reviewing the Oncology Value Management program prior authorization list for Blue Cross and BCN commercial members To determine which commercial self-funded groups have requirements under the program, see the Oncology Value Management program participation list for self-funded groups. Submit the prior authorization request to OncoHealth.	For additional information, see the Oncology Value Management program through OncoHealth: FAQs for providers. If you have questions about the Oncology Value Management program, call OncoHealth at 1-888-916-2616.
Blue Cross Blue Shield of Michigan commercial	For Blue Cross commercial UAW Retiree Medical Benefits Trust members: Determine whether the drug requires prior authorization through OncoHealth by reviewing the Oncology Value Management program prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members: Medications that require authorization by Carelon. Submit the prior authorization request to Carelon Medical Benefits Management.	For additional information, refer to the Oncology Value Management program through Carelon: FAQs for providers.
Blue Care Network commercial	Determine whether the drug requires prior authorization through OncoHealth by reviewing the Oncology Value Management program prior authorization list for Blue Cross and BCN commercial members. To determine which commercial self-funded groups have requirements under the program, see the Oncology Value Management program participation list for self-funded groups. Submit the prior authorization request to OncoHealth.	For additional information, see the Oncology Value Management program through OncoHealth: FAQs for providers. If you have questions about the Oncology Value Management program, call OncoHealth at 1-888-916-2616.
Medicare Plus Blue^℠ or BCN Advantage^℠	Determine whether the drug requires prior authorization through OncoHealth by reviewing the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members. Submit the prior authorization request to OncoHealth.	For additional information, see the Oncology Value Management program through OncoHealth: FAQs for providers. If you have questions about the Oncology Value Management program, call OncoHealth at 1-888-916-2616.

Note: When prescribing these drugs for non-oncology diagnoses, don't submit prior authorization requests as instructed above. Instead, fax all clinical documentation to the Pharmacy Clinical Help Desk at 1-877-325-5979.

Training Resources

OncoHealth OneUM^™ prior authorization portal

To learn how to use the OncoHealth portal, go to Blue Cross and BCN's Provider Training site, search on oncology and launch the "OncoHealth presentation." (For detailed information about accessing the Provider Training site, see the "Online training" section of the Training Tools page)

NDC billing

To learn about National Drug Code billing, go to Blue Cross and BCN's Provider Training site, searching on NDC and launch the "National Drug Code billing for medical drug benefits e-Learning." (For detailed information about accessing the Provider Training site, see the "Online training" section of the Training Tools page.)

How to submit prior authorization requests

To learn how to submit requests, see our Getting Started page.

Submit requests before providing services.

Utilization Management Criteria

Visit our Utilization Management Criteria page.

Availity® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

OncoHealth is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

Medical Benefit Drugs: How to determine requirements for oncology medical benefit drugs

Training Resources

OncoHealth OneUM™ prior authorization portal

NDC billing

How to submit prior authorization requests

Utilization Management Criteria

OncoHealth OneUM^™ prior authorization portal