CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Utilization management medical drug list (FEP non‑Medicare)

Lists medical‑benefit drugs that require prior authorization for Blue Cross and Blue Shield Federal Employee Program (FEP) non‑Medicare members receiving drugs in Michigan; affects providers who administer these drugs in Michigan.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyUtilization management medical drug list (FEP non‑Medicare)

Policy CodePolicy N/A

Change TypeAdministrative revision — no material clinical changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionRequest prior authorization using FEP Medication Authorization Request Forms for listed medical‑benefit drugs administered in Michigan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200drugs or HCPCS/J-codes listed

Michigan-onlyauthorization scope

Revised Apr 1, 2026document revision date

variesauthorization effective dates

Coverage Criteria

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Authorization requirement: Member is a Blue Cross and Blue Shield Federal Employee Program (FEP) non‑Medicare member AND the drug (identified by HCPCS/J/Q code) is listed in this document AND the drug is administered in Michigan

This list does not include clinical indication–specific criteria; separate clinical policies or forms may be required.

Authorization is required for the medical-benefit drugs listed in this document only when the member receives the drug in Michigan. The list identifies HCPCS/J/Q codes that require prior authorization for Blue Cross and Blue Shield Federal Employee Program (FEP) non-Medicare members; drugs administered outside Michigan are not subject to these authorization requirements.

Coding / Billing Codes

Sample listed HCPCS/J/Q codes (document contains many more)mixedCovered

Q2055	Abecma (idecabtagene vicleucel)
J9042	Adcetris (brentuximab vedotin)
J9029	Adstiladrin (nadofaragene firadenovec- vncg)
Q5150	Ahzantive (aflibercept-mrbb)
J1552	Alyglo (immune globulin intravenous)

Additional listed HCPCS/J codesmixedCovered

J1745	Infliximab / Remicade
J2506	Neulasta (Pegfilgrastim)
J9312	Rituxan (rituximab)
J9271	Keytruda (pembrolizumab)
J3590	Multiple product-specific usages (unclassified biologics/ATMPs listed under J3590 in this document)

Provider Actions / Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required for the medical-benefit drugs listed in this document when they are administered to members in Michigan. Providers must request authorization from Blue Cross Blue Shield of Michigan for the listed HCPCS/J codes for the dates specified in the drug list.

Authorization required only when drugs are administered in Michigan
Providers must use FEP Medication Authorization Request Forms to submit requests

Step Therapy

No step therapy rules or step sequences are specified in this document. This list solely identifies drugs and HCPCS/J/Q codes that require prior authorization; it does not impose step therapy requirements.

Denial Risk

Authorization Request Process and Denial Risk

Providers must request authorization using the FEP Medication Authorization Request Forms for medical-benefit drugs listed in this document. Failure to request prior authorization for drugs listed when administered in Michigan may result in non-coverage or denial of payment.

Use the FEP Medication Authorization Request Form to submit prior authorization requests
Failure to obtain authorization when required may lead to claim denial or non-coverage

Background

This document is an administrative listing of medical-benefit drugs that have authorization requirements for Blue Cross and Blue Shield Federal Employee Program (FEP) non-Medicare members. It provides the drug billing codes and effective authorization dates but does not include clinical coverage criteria or indication-specific clinical justification.

Definitions / Forms

Authorization form referenced for submitting prior authorization requests

Authorization form nameFEP Medication Authorization Request Forms

PurposeForm used by providers to request prior authorization for medical-benefit drugs for FEP non-Medicare members when administered in Michigan

Access noteFEP Medication Authorization Request Forms can be accessed via the link provided in the policy document

ApplicabilityRequired for prior authorization requests for drugs listed in this medical drug list for Blue Cross and Blue Shield FEP non-Medicare members

Effective contextAuthorization using these forms is required for dates of service on or after Dec. 1, 2020, when drugs are received in Michigan

Requirement	Details
Step-therapy sequencing or fail-first steps specified
No step-therapy sequencing or fail-first steps are specified in this document; the list only identifies medical-benefit drugs (by HCPCS/J/Q codes) that require prior authorization when administered in Michigan.

Site of Care

Note

Authorization applies when drug is administered in Michigan (site-of-care)

The prior-authorization requirement applies when the drug is administered in Michigan, including administration in infusion centers; providers must obtain authorization for listed drugs given in Michigan.

Authorization applies to medical-benefit drugs administered to FEP non-Medicare members in Michigan.