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Behavioral Health Management

Our Behaviorial Health Management Department focuses on improving the quality of life for people suffering from mental health or substance abuse issues (MHSA) and is a key aspect of a person’s overall health and wellbeing. Learn More >>>

Mental Health Parity

The Mental Health Parity Act is effective October 3, 2009. Click here to learn more about the Act and how it affects you. Learn More >>>

Drugs Requiring Prior Authorization

The following drugs require prior authorization. All requests for coverage of these drugs must be referred to Blue Cross of Idaho's Pharmacy Benefits Management Department. Please have your doctor complete the Pharmacy Prior Authorization Form and fax to (208) 387-6969.

These requirements do not apply to Medicare Advantage plans, Medicare supplement plans, individual policies (e.g. Personal Blue, HSA Blue and Essential Blue Basic products) and group contracts that do not have specific pharmacy benefits.

Updated: June 1, 2009

Afinitor (everolimus)

Amevive (alefacept)

*Aralast (alpha-1-proteinase inhibitor)

Avastin (bevacizumab)

Boniva IV (ibandronate)

Botox (botulinum toxin type A)

Celebrex (celecoxib), see COX-2 info

*Cerezyme (imiglucerase)

Cimzia (certolizumab)

Cinryze (c1 esterase inhibitor)

Elaprase (idursulfase)

Enbrel (etanercept)

*Fabrazyme (agalsidase beta)

Factor

Fentora (fentanyl)

Fentora guidelines

Fentora prior auth form

Folotyn (pralatrexate)

Forteo (teriparatide)

Gleevec (imatinib mesylate)

Growth Hormone

Humira (adalimumab)

Hyalgan (sodium hyaluronate)

Hycamtin (topotecan)

Implanon (etonagestrel)

Intravenous Immune Globulin (IVIG)

Iressa (gefitinib)

Ixempra (ixabepilone)

Kineret (anakinra)

Letairis (ambrisentan)

Lovenox (enoxaparin sodium)

Lucentis (ranibizumab)

Mircera (epoetin beta)

Mozobil (plerixafor)

Myobloc (botulinum toxin type B)

*Myozyme (alglucosidase alfa)

*Naglazyme (Galsulfase)

Nexavar (sorafenib)

Nplate (romiplostim)

All Forms of Contraceptives (if coverage

of birth control is excluded)

Orencia (abatacept)

OrthoVisc (sodium hyaluronate)

Prialt (ziconotide)

*Prolastin (alpha-1-proteinase inhibitor)

Reclast (zoledronic acid)

Regranex (becaplermin)

Remicade (infliximab)

RespiGam (IVIG)

Revatio (sildenafil)

Revlimid (lenalidomide)

Rituxan (rituximab)

Simponi (golimumab)

Somatuline (lanreotide)

Soliris (eculizumab)

Sprycel (dasatinib)

Stelara (ustekinumab)

Supartz (sodium hyaluronate)

Sutent (sunitinib malate)

Synagis (palivizumab)

Synvisc (sodium hyaluronate)

Tarceva (erlotinib)

Tasigna (nilotinib)

Temodar (temozolomide)

Torisel (temsirolimus)

Treanda (bendamustine)

Tykerb (lapatinib)

Tysabri (natalizumab)

Velcade (bortezomib)

Vivaglobin (subcutaneous IVIG)

Xeloda (capecitabine)

Xigris (protein C)

Xolair (omalizumab)

*Zemaira (alpha-1-proteinase inhibitor)

Zolinza (vorinostat)

NOTE: Not all of these drugs are available through the WellPoint NextRx Pharmacy Network but are listed here for your information.

All medications being used for an off-label indication must have prior authorization.

*Cerezyme, Myozyme, Fabrazyme and Naglazyme, Aralast, Prolastin, Zemaira are reviewed by Case Management.

This is not an all-inclusive list and is subject to change. If you have any questions, please contact the Pharmacy Management Department at (208) 387-6666 or (800) 274-4018, Ext. 6666.

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