Medical Benefit Drugs: How to determine requirements for most 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
Blue Cross Blue Shield of Michigan commercial	Determine whether there are prior authorization or site-of-care requirements by reviewing the appropriate drug list: Standard commercial medical drug program Blue Cross and BCN utilization management medical drug list For Lemtrada^® and Tysabri^®, see the drug list for additional information related to the site-of-care requirements. To determine which Blue Cross commercial self-funded groups have opted in to the standard commercial drug program, see Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. Group-specific medical drug program UAW Retiree Medical Benefits Trust non-Medicare members: Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members FEP^® non-Medicare members: Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members Determine whether there are quantity limits by reviewing Blue Cross and BCN quantity limits for medical drugs. Submit the prior authorization request through the Medical and Pharmacy Drug PA Portal, which is accessed by clicking the Medical and Pharmacy Benefit Drug Prior Auth tile in our provider portal (availity.com).
Blue Care Network commercial	Determine whether there are prior authorization or site-of-care requirements by reviewing the Blue Cross and BCN utilization management medical drug list. For Lemtrada and Tysabri, see the drug list for additional information related to the site-of-care requirements. Determine whether there are quantity limits by reviewing the document titled Blue Cross and BCN quantity limits for medical drugs. Submit the prior authorization request through the Medical and Pharmacy Drug PA Portal, which is accessed by clicking the Medical and Pharmacy Benefit Drug Prior Auth tile in our provider portal (availity.com).
Medicare Plus Blue^℠ or BCN Advantage^℠	Confirm that the drug requires prior authorization by reviewing the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members. Submit the prior authorization request through the Medical and Pharmacy Drug PA Portal, which is accessed by clicking the Medical and Pharmacy Benefit Drug Prior Auth tile in our provider portal (availity.com).

If you experience issues while working in the Medical and Pharmacy Drug PA Portal, click Contact Us near the upper right corner of the Medical and Pharmacy Drug PA Portal.

Training Resources

Medical and Pharmacy Drug PA Portal

To learn how to use the Medical and Pharmacy Drug PA Portal, view a recorded demo by going to Blue Cross and BCN's Provider Training site, searching on drugs and launching the "Medical and Pharmacy Drug PA Portal Overview Mini Module." (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.