Step therapy requirement to be added for VPRIV, Elelyso for Medicare Advantage members, starting June 1

For dates of service on or after June 1, 2024, health care providers must show that Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Cerezyme^® (imiglucerase) when requesting prior authorization for the following drugs:

• VPRIV^® (velaglucerase alfa), HCPCS code J3385
• Elelyso^® (taliglucerase alfa), HCPCS code J3060

Cerezyme is Blue Cross Blue Shield of Michigan and Blue Care Network’s preferred enzyme replacement therapy for Gaucher disease.

These drugs are covered under members’ medical benefits, not their pharmacy benefits.

Providers should submit prior authorization requests for VPRIV and Elelyso through the NovoLogix^® online tool.

As a reminder, Cerezyme doesn’t require prior authorization for dates of service on or after Jan. 1, 2024.

When prior authorization is required

VPRIV and Elelyso require prior authorization when they are administered by a 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 form
• Electronically through an 837I transaction or using the UB04 claim form for a hospital outpatient type of bill 013X

Submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal at availity.com,** click Payer Spaces in the menu bar and then click 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 on bcbsm.com.  

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 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.