Step therapy requirement added for botulinum toxins for Medicare Advantage members, starting Aug. 5

For dates of service on or after Aug. 5, 2024, health care providers must show that Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Xeomin^® (incobotulinumtoxinA), HCPCS code J0588, when requesting prior authorization for the following drugs:

• Botox^® (onabotulinumtoxinA), HCPCS code J0585
• Dysport^® (abobotulinumtoxinA), HCPCS code J0586
• Daxxify^® (daxibotulinumtoxinA), HCPCS code J0589
• Myobloc^® (rimabotulinumtoxinB), HCPCS code J0587

Xeomin is the preferred botulinum toxin product for Blue Cross Blue Shield of Michigan and Blue Care Network’s Medicare Advantage members.

The following is additional important information:

• Step therapy with Xeomin won’t be required for requests to treat chronic migraines or urinary conditions such as overactive bladder.
• Xeomin doesn’t require prior authorization for dates of service after June 1, 2024. For dates of service before June 1, submit prior authorization requests through the NovoLogix^® online tool.
• Submit prior authorization requests for Botox, Dysport, Myobloc and Daxxify through NovoLogix.

These drugs are a part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These drugs require prior authorization, as applicable, when they are administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

• Electronically through an 837P transaction or on a professional CMS-1500 claim
• Electronically through an 837I transaction or using the UB04 claim for a hospital outpatient type of bill 013X

How to submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal at availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. 

If you need to request access to our provider portal, follow the instructions on the Register for web tools page at bcbsm.com.

List of requirements

For a list of requirements related to drugs covered under medical benefits, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members.

We’ll update this list prior to the effective date.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

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

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.