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Additional drugs to require prior authorization for Medicare Advantage members, starting May 11
Effective date
May 11, 2026
Identified
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).
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What to do
Action · 4 steps
01Before 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.
02Access the Medical and Pharmacy Drug PA Portal through availity.com to submit prior authorization requests.
03Update encounter forms to alert providers that these drugs require prior auth when billed on CMS-1500 or UB04 forms.
04Claims will be denied without proper prior authorization.
Codes mentioned
Q5161J1599J3404J3590
Original notice
Additional drugs to require prior authorization for Medicare Advantage members, starting May 11
bcbsm.com · Always check the source before changing claims.
Related changes
See all BCBS Michigan changes →HCPCS replacement codes established, effective April 1, 2026MediumEffective Apr 1, 2026 · CodingHCPCS 1st-quarter update: New, deleted codesHighEffective Apr 1, 2026 · CodingHCPCS replacement codes established, effective July 1, 2026HighEffective Jul 1, 2026 · CodingAdditional drugs to have site-of-care requirement for most commercial, URMBT members, starting July 1MediumEffective Jul 1, 2026 · Prior AuthorizationBrowse every BCBS Michigan change in the policy list