08/18/2025

BCBSM/BCN

Recent Oncology Related News

Blue Cross Blue Shield / Blue Care Network Managed Care Committee Members:

Vernell Hester, COC, CHONC - Downriver Oncology Center

BCN Updated Fees for Some Codes Effective Aug. 1
Effective Aug. 1, 2025, Blue Care Network is changing the reimbursement rates for some procedure codes.  These changes apply to the BCN commercial fee schedule. The procedure codes that have fee changes effective Aug. 1 are for durable medical equipment or drugs.

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We’re Changing How We Manage Self-Administered Hemophilia Products for Most Blue Cross, BCN Commercial Members, Starting Sept. 1
Starting Sept. 1, 2025, self-administered formulations of hemophilia products will no longer be payable under medical benefits for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. Instead, they’ll be payable under pharmacy benefits. This change doesn’t apply to Medicare Advantage groups or members.

Some members recently received a self-administered hemophilia product that was administered by a health care provider and billed under their medical benefits. Authorizations for self-administered hemophilia products will remain in effect under medical benefits until Aug. 31, 2025. If the hemophilia product they’re taking doesn't require prior authorization under medical benefits, no prior authorization is needed to transition to pharmacy benefits. 

A new authorization for a self-administered hemophilia product will be approved Sept. 1, 2025, under pharmacy benefits and active through Aug. 31, 2026, so members can continue therapy without interruption. Members can fill their prescriptions at in-network retail pharmacies.

On or after Sept. 1, there will be no coverage provided for any self-administered hemophilia products through medical benefits.

If members don’t have prescription coverage through Blue Cross or BCN and are currently filling their prescription for these medications through their Blue Cross or BCN medical benefit, they can check to see if their pharmacy plan will cover it.

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Starting Sept. 1, We’ll Change How We Pay for Certain Medications for Most Blue Cross, BCN Commercial Members
The table below shows the medications we won’t pay for starting Sept. 1, 2025, as well as the alternative medications we’ll pay for starting Sept. 1. These drugs are managed through the Oncology Value Management program, which is administered by OncoHealth.

These changes will affect most Blue Cross Blue Shield of Michigan and Blue Care Network commercial members with pharmacy benefits. These changes won’t apply to Medicare Advantage groups or members.

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Starting Oct. 6, Submit Prior Authorization Requests for FEP Members Through the E-Referral System
Starting Oct. 6, 2025, health care providers can submit prior authorization requests for members who have coverage through the Blue Cross and Blue Shield Federal Employee Program through the e-referral system. This change applies to procedures that are managed by Blue Cross Blue Shield of Michigan and affects FEP members who have both commercial and Medicare Supplement plans.

This change will benefit you by:

• Enabling you to submit prior authorization requests for FEP members in the same way you submit requests for other Blue Cross members
• Helping to decrease the time it takes for Blue Cross to process prior authorization requests
• Enabling you to quickly and easily check the status of prior authorization requests through the e-referral system
• Enabling you to communicate with Blue Cross staff through the Case Communication field in the e-referral system

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Reminder: Follow These Requirements When Billing for Non-Covered Services
Blue Cross Blue Shield of Michigan has been informed that some health care providers have been billing our members for services that have been deemed “provider liable” on their remittance advice or payment vouchers.

This action doesn’t align with the terms outlined in our provider agreements. As a result, we’re reminding our participating health care providers that they’re required to comply with the terms of their contracts.

While our provider contracts allow members to choose to pay for non-covered services, providers must follow the steps outlined below before rendering the service:

1. Advise the member in writing that Blue Cross won’t make payment for the specific service because Blue Cross considers it experimental or not medically necessary.
2. Advise the member in writing that he or she will be financially responsible for the specific service.
3. Advise the member in writing of the estimated cost for the specific service.
4. Obtain the member’s signed consent to receive and pay for the specific service.

All provider agreements, including the Participating Hospital Agreement (Article II, Section 7[b]) and the Traditional Professional Provider Agreement (Addendum F, Section 2), contain steps like those listed above. 

A general financial form stating that the member is responsible for additional costs not covered by insurance isn’t sufficient to meet this requirement. You must obtain a specific, signed agreement from the member for each noncovered service.

Action required
To avoid any issues, immediately stop billing members for amounts exceeding their cost share or provide a compliant agreement signed by the member to support continued billing.

Failure to follow this process may result in additional action by Blue Cross, up to and including termination of the provider or facility contract.