Upcoming Prior Authorization Changes from Blue Cross

BCBSM/BCN – Prior Authorization for some Diabetes Drugs

Beginning August 15, 2023, health care providers for Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) commercial members will need to obtain prior authorization to show that the brand-name medications listed below are being used for Type 2 diabetes for us to pay for them. Medicare members are excluded from this change.

BCBSM/BCN – Elahere, Imjudo, Tecvayli and Lunsumio to Require Prior Authorization

For dates of service on or after August 23, 2023, Elahere, Imjudo, Tecvayli and Lunsumio will require prior authorization through Carelon Medical Benefits Management (formerly known as AIM Specialty Health®) for most BCBSM and BCN group and individual commercial members.

BCBSM/BCN – Clarification: Xgeva continues to require prior authorization through NovoLogix for most commercial members

Xgeva® (denosumab), HCPCS code J0897, continues to require prior authorization for most BCBSM and BCN group and individual commercial members. Physicians should submit prior authorization requests for these members through the NovoLogix® online tool.

Note: On Dec. 6, 2022, we published a provider alert stating that Xgeva would no longer require prior authorization through Carelon Medical Benefits Management (formerly known as AIM Specialty Health®). That change applied only to Medicare Plus Blue℠ and BCN Advantage℠ members, starting January 1, 2023.

BCBSM/BCN – Updated List of Musculoskeletal Procedure Codes that Require Prior Authorization

The Blues recently updated the Musculoskeletal procedure codes that require authorization by TurningPoint document to reflect the following changes:

  • For dates of service on or after March 19, 2023, procedure code *64625 is no longer payable for Medicare Plus Blue℠ or BCN Advantage℠ members.
    Note: This procedure code continues to be payable for BCBSM and BCN commercial members. It requires prior authorization for BCN commercial members. It does not require prior authorization for Blue Cross commercial members.
  • For dates of service on or after March 25, 2023, procedure code C1767 does not require prior authorization for Medicare Plus Blue, BCN commercial or BCN Advantage members.
    Note: This procedure code has never required prior authorization for Blue Cross commercial members.
  • For dates of service on or after July 1, 2023, procedure code *0775T will require authorization for Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage members.

Meridian Health Plan – Help Patients with Transportation Needs

Physicians can assist their Meridian patients with transportation to medical appointments by scheduling non-emergency transportation to and from their appointments and pharmacy. For more information on how to schedule Meridian patient transportation, the flyer is available for download or by visiting the Manuals, Forms, and Resources page on mimeridian.com

Meridian Health Plan – New Z-Code Provider Incentive Program

Meridian recognizes that health care goes beyond standard testing and treatments and includes screening patients for social determinants (SDoH) that may be having a negative impact on their health. To reward physicians for this work, Meridian is rolling out a new Z-Code SDoH Provider Incentive Program. Effective June 1, 2023, physicians are eligible to receive incentives for screening patients for SDoH needs.