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Blue Cross Blue Shield of Minnesota: Implementation of a Medical Drug Exclusions List

At Blue Shield of Minnesota (BCBSMN), member safety is a top concern.

As stewards of healthcare expenditures for our members, we are charged with ensuring the highest quality, evidence based care for our members. To accomplish this, when multiple versions of the same drug exist, BCBSMN may cover only certain versions of the drug after completing a review of the medical drugs. This will apply our members who may be treated by your contracted providers. Please share this information with your provider service representatives.

What is changing?
Effective December 1, 2017, BCBSMN will not be covering the following non-preferred drugs under the medical benefit, as an alternative preferred medical drug is available, when member’s meet medical necessity criteria.

Medical Drug Exclusions – effective December 1, 2017.

Effective December 1, 2017 - the following non-preferred drugs will NOT be covered under the medical benefit.

Preferred Medical Drug

Excluded Drug Alternatives
(Not Covered)
Products Impacted
Brand Name NDC
Brand Name NDC
SynVisc-One® 58468009003 J7325 GenVisc 850® 50653000601 J7320
  • Commercial health plans
  • Prepaid Medical Assistance Program (PMAP)
  • MinnesotaCare (MNCare)
  • Minnesota Senior Care Plus (MSC+)
  • SecureBlue (MSHO)
SynVisc® 58468009001 J7325 Hyalgan 54569554300 J7321
Supartz® 89130444401 J7320
Hymovis® 89122049663 J7322
Euflexxa® 55566410001 J7323
OrthoVisc® 59676036001 J7324
Gel-One® 87541030091 J7326
MoniVisc® 59676082001 J7327
Gelsyn 3® 89130311101 J7328
Infliximab** Remicade® 57894003001 J1745 Inflectra™ 00069080901 Q5102
  • Commercial health plans
Renflexis™ 00006430501 Q5102

*See BCBSMN medical policy II-29 - Intra-Articular Hyaluronan Injections for Osteoarthritis.
**See BCBSMN medical policy II-97 - Infliximab.

Please note, this exclusion does not impact members who have coverage through Federal Employee Program or Platinum Blue (Medicare Cost Plan), as those lines of business have separate PA requirements.

Beginning December 1, 2017, if the services listed above are not preauthorized by your contracted providers for BCBSMN members they treat, the claims may be denied and our members may be responsible for payment of the charges. In addition, if a pre-service review is submitted and not approved, but the service is provided, members may be held liable for service charges determined to be not medically necessary.

Out of area providers can access BCBSMN’s medical policy information and conduct pre-service review for BCBSMN members through NaviNet’s Horizon BCBSNJ plan central page.

If you have questions, please speak with a BCBSMN provider service representative by calling the BlueCard Eligibility line at 1-800-676-BLUE (2583). If the BCBSMN member’s ID card does not include an alpha prefix, please call the provider service phone number on the ID card.