Step therapy requirement added for Saphnelo for Medicare Advantage members Sept. 1

For dates of service on or after Sept. 1, 2024, providers will have to show that our Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Benlysta^® (belimumab), HCPCS code J0490, when requesting prior authorization for Saphnelo^® (anifrolumab-fnia), HCPCS code J0491.

• Benlysta will continue to require prior authorization.
• Submit prior authorization requests through the NovoLogix^® online tool.

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’re 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

Submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal (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. 

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

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 before the effective date.

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

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.