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September 2018

Medical Drug Prior Authorization and Site of Care programs to expand

Blue Cross Blue Shield of Michigan and Blue Care Network are expanding our medical drug management programs for commercial members. We encourage proper utilization of high-cost specialty medications administered by a health care provider.

Beginning Oct. 1, 2018, Trogarzo™ and Zilretta® will be added to the Medical Drug Prior Authorization program for HMO and PPO commercial lines of business. Trogarzo will also be added to the Site of Care program for HMO members, effective Oct. 1, 2018.

Trogarzo is used to treat human immunodeficiency virus type-1 infection for heavily treatment-experienced adults with multi-drug resistant HIV-1 infection failing their current antiretroviral regimen. Zilretta is a single dose intra-articular injection. It’s FDA-approved for the management of osteoarthritis knee pain.

Brand name

HCPCS code

Generic name

Prior Authorization program

Site of Care program

Trogarzo™

J3590

Ibalizumab-uiyk

 

HMO and PPO

HMO only

Zilretta®

Q9993

Triamcinolone Acetonide extended release

No

Members currently on Trogarzo don’t have to do anything.

Members currently on Zilretta need a prior authorization on or after Oct. 1, 2018.

A prior authorization approval isn’t a guarantee of payment. Health care practitioners must verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

Refer to the opt-out list for the groups that don’t require members to participate in the programs. To access the list, follow these steps:

  1. Log in to Provider Secured Services.
  2. Click BCBSM Provider Publications and Resources.
  3. Click Newsletters & Resources.
  4. Click Forms.
  5. Click Physician administered medications.
  6. Click BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

These changes don’t apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.

For a full list of drugs in the prior authorization program:

BCN

  1. Go to ereferrals.bcbsm.com.
  2. Select BCN at the top
  3. Click BCN-Authorizations/Referrals
  4. Click on the link for Medical Benefit Drugs – Pharmacy
  5. Click Requirements for drugs covered under the medical benefit – BCN HMO underneath For BCN HMO (commercial) members.

Blue Cross

  1. Log in as a provider at bcbsm.com/providers.
  2. Click BCBSM Provider Publications and Resources on the lower right side of the page.
  3. Click Newsletters and Resources.
  4. Click the Forms link in the left navigation.
  5. Click Physician administered medications.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.