Drugs Requiring Prior Authorization
All medications being used for an off-label indication must have prior authorization.
The following drugs and/or drug classes require prior authorization. All requests for coverage of these drugs must be referred to Blue Cross of Idaho`s Pharmacy Management Department. Please have your doctor complete the Pharmacy Prior Authorization Form and fax to (208) 387-6969.
Medical Policies address other drug/drug classes which may or may not be listed below. From this website, please enter the name or drug class in the upper right hand search box to find out if it is referenced in a Medical Policy. You may need to perform your search by the brand name, generic name and/or drug class. If a medical policy exists for that drug, the search engine will locate it. Some of the drugs listed below are also linked to Medical Policies. To access these Medical Policies, just click the link on the drug name.
Group contracts, Medicare Advantage plans, Medicare supplement plans, individual policies (e.g. Personal Blue, HSA Blue and Essential Blue products) that do not have specific pharmacy benefits may have additional prior authorization requirements. If you have questions regarding this matter, please contact our Customer Services Department using the contact information provided on the back of the member's ID card.
(Direct Link to Medicare Part B Prior Authorization Drugs)
(Direct Link to Medicare Part D Drug Benefits)
This is not an all-inclusive list and is subject to change.
Updated: November 2013
Drug Class Section: NOTE: Individual drug names not listed here.
ALL OUTPATIENT INTRAVENOUS THERAPY
If drug names not listed here see also drug class section above.
Extavia (interferon Beta-1b) Step Therapy guidelines
Gleevec (imatinib mesylate)
Orthovisc (intra-articular Hyaluronan Injection)
Prolastin (alpha-1-proteinase inhibitor)
Reclast (zoledronic acid)
Supartz (intra-articular Hyaluronan Injection)
Sutent (sunitinib malate)
Synribo (omacetaxine mepesuccinate)
Synvisc-One (intra-articular Hyaluronan Injection)
Victoza (liraglutide) PA form & Guidelines