April 2022
Enjaymo, Vabysmo and Byooviz to require prior authorization for Medicare Advantage members
Providers must submit prior authorization requests through the NovoLogix® online tool for the following drugs covered under the medical benefit for our Medicare Advantage members:
- For dates of service on or after March 7, 2022:
- Enjaymo™ (sutimlimab-jome), HCPCS code J3590
- Vabysmo™ (faricimab-svoa), HCPCS code J3590
- For dates of service on or after June 6, 2022:
- Byooviz® (ranibizumab-nuna), HCPCS code J3590
This requirement applies to Medicare Plus Blue℠ and BCN Advantage℠ members.
When prior authorization is required
We require prior authorization when these drugs are administered in any site of care other than inpatient hospital (place of service code 21) and are billed as follows:
- Electronically through an 837P transaction or on a professional CMS-1500 claim form
- Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x
Submitting prior-authorization requests
Submit prior authorization requests for these drugs through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to NovoLogix.
If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.
List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.
We'll update the list to reflect these changes prior to the effective date. |