May 2024
Requirements and codes changed for some medical benefit drugs
Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain comprehensive lists of requirements for our members.
In January, February and March 2024, we added requirements for some medical benefit drugs. These requirements went into effect on various dates. In addition, some drugs were assigned new HCPCS codes.
Changes in requirements
For Blue Cross commercial and BCN commercial members, we added prior authorization requirements, site-of-care requirements or both for the following drugs:
HCPCS code |
Brand name |
Generic name |
Requirement |
Prior authorization |
Site of care |
J1599 |
Alyglo™ |
Immune globulin intravenous, human-stwk 10% |
✓ |
✓ |
J3590** |
Amtagvi™ |
Lifileucel |
✓ |
|
J3590** |
Avzivi® |
Bevacizumab-tnjn |
✓ |
|
J3590** |
Ryzneuta® |
Efbemalenograstim alfa-vuxw |
✓ |
|
For Medicare Plus Blue℠ and BCN Advantage℠ members, we added prior authorization requirements for the following drugs:
HCPCS code |
Brand name |
Generic name |
For dates of service on or after |
J3590 |
Casgevy™ |
Exagamglogene autotemcel |
Jan. 2, 2024 |
J3590 |
Lyfgenia™ |
Lovotibeglogene autotemcel |
Jan. 2, 2024 |
J3490 |
Omisirge® |
Omidubicel-onlv |
Feb. 1, 2024 |
J3590 |
Bimzelx® |
Bimekizumab-bkzx |
Feb. 12, 2024 |
J3590 |
Cosentyx® IV |
Secukinumab |
Feb. 12, 2024 |
J3590 |
Omvoh™ IV |
Mirikizumab-mrkz |
Feb. 12, 2024 |
J3590 |
Pombiliti™ |
Cipaglucosidase alfa-atga |
Feb. 12, 2024 |
J3490 |
Rivfloza™ |
Nedosiran |
Feb. 12, 2024 |
J3490 |
Zilbrysq® |
Zilucoplan |
Feb. 12, 2024 |
J3590 |
Zymfentra™ SC |
Infliximab-dyyb |
Feb. 12, 2024 |
J3590 |
Adzynma |
ADAMTS13, recombinant-krhn |
March 1, 2024 |
J3490 |
Wainua™ |
Eplontersen |
March 1, 2024 |
Code changes
The table below shows HCPCS code changes that were effective January 2024 for the medical benefit drugs managed by Blue Cross and BCN.
New HCPCS code |
Brand name |
Generic name |
J0217 |
Lamzede® |
Velmanase alfa |
J1304 |
Qalsody® |
Tofersen |
J1412 |
Roctavian™ |
Valoctocogene roxaparvovec-rvox |
J1413 |
Elevidys |
Delandistrogene moxeparvovec-rokl |
J2508 |
Elfabrio® |
Pegunigalsidase alfa-iwxj |
J3401 |
Vyjuvek® |
Beremagene geperpavec-svdt |
J9333 |
Rystiggo® |
Rozanolixizumab-noli |
J9334 |
Vyvgart® Hytrulo |
Efgartigimod alfa and hyaluronidase-qvfc |
Drug lists
For additional details, see the following drug lists:
These lists are also available on the following pages of the ereferrals.bcbsm.com website:
Additional information about these requirements
We communicated these changes previously through provider alerts, which contain additional details.
You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal, availity.com.***
Additional information for Blue Cross commercial groups
For Blue Cross commercial groups, authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.
Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.
Reminder
An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.
**May be assigned a unique code in the future.
***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.
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