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) 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) 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.
Find a Provider
Medicare
Prescription Drugs
Medicare Formulary