Medicare AdvantagePrior AuthMedium impact
Additional drugs to require prior authorization for Medicare Advantage members, starting May 11
BCBS Michigan·MI · Oncology, Rheumatology, Endocrinology +2 more·Prior Authorization
Effective date
May 11, 2026
We identified it
Jun 16, 2026
Summary
Starting May 11, 2026, five additional drugs will require prior authorization for Medicare Plus Blue and BCN Advantage members when billed under medical benefits. This includes bone health drugs (Aukelso, Bosaya), immune globulin (Gammagard Liquid ERC), gene therapy (Papzimeos), and biologic therapy (Starjemza IV).
Action Required
Before May 11, 2026: Billing team must update prior authorization requirements in billing system for HCPCS codes Q5161, J1599, J3404, and J3590 for Medicare Plus Blue and BCN Advantage members. Access the Medical and Pharmacy Drug PA Portal through availity.com to submit prior authorization requests. Update encounter forms to alert providers that these drugs require prior auth when billed on CMS-1500 or UB04 forms. Claims will be denied without proper prior authorization.