Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

New Options for Affordable Health Insurance
Blue Cross of Idaho Medicare Advantage Plans prior authorizes specific drugs to be covered under Part B.
  • Failure to obtain prior authorization may impact reimbursement
  • All requests for determination of coverage of these drugs must be referred to Medicare Advantage Medical Review Department (208) 395-8210 or (800) 743-1871
  • The doctor must complete the Medicare Advantage Prior Authorization form at www.bcidaho.com and fax it to (208) 286-3555
  • All medications being used for off-label indication must be prior authorized
  • This is not an all-inclusive list, and is subject to change. Updates will be done on a quarterly basis
  • Please note when drugs listed below are not covered by Part B, they may be covered by Part D

 

The following drugs, listed with appropriate code(s) require Prior Authorization:
Last updated January 27,2014

 

Brand Name

Generic Name

Applicable Code

Actemra

tocilizumab

J3262

Adcetris

brentiximab vedotin, injection

J9042

Amevive

alefacept

J0215

Aldurazyme

laronidase

J1931

Blood Clotting Factors

Antihemophiliac Products require prior authorization

 

Wilate

Willebrand factor/coagulation Factor VIII complex (Human)

J7183

Alphanate VWF complex

Von Willebrand Factor complex Human ristocetin Cofactor

J7187

Corifact

Injection, factor XIII (antihemophilic factor, human), 1 IU

J7180

Xyntha

Injection, factor VIII (antihemophilic factor, recombinant) (xyntha), per I.U. 

J7185

 

Injection, antihemophiliac factor VIII/ Von Willebrand factor complex

J7186

 

Factor viia (antihemophilic factor, recombinant), per 1 microgram

J7189

Monarc-M

Factor VIII (anti-hemophilic factor, human) per IU

J7190

Product discontinued

Factor VIII (anti-hemophilic factor, porcine) per IU

J7191

 

Factor VIII (antihemophilic factor, recombinant) Per I.U.

J7192

 

Factor IX (antihemophilic factor, purified, non-recombinant) per I.U.

J7193

Konyne-80,
Profilnine Heat Treated, Proplex T, Proplex SX-T

Factor IX complex, per IU

J7194

 

Factor IX (antihemophilic factor, recombinant) oer I.U.

J7195

 

Injection, antithrombin recombinant, 50 I.U.

J7196

Thrombate III

Antithrombin III (human), per IU

J7197

 

Anti-inhibitor, per IU

J7198

 

Hemophilia clotting factor, not otherwise classified

J7199

Aralast

Alpha 1-proteinase inhibitor-human

J0256

Arzerra

ofatumumab injection

J9302

Avastin

bevacizumab

J9035
C9257

Benlysta

Injection, belimumab, 10mg

J0490

Berinert

Injection, C-1 esterase inhibitor (human), 10 units

J0597

Boniva

ibandronate sodium

J1740

Botox

botulinum toxin type A

J0585, J0586, J0588

Cerezyme

injection, imiglucerase 10 units

J1786

Cidofovir

vistide 75mg

J0740

Cimzia

certolizumab

J0718

Cinryze

C1 esterase inhibitor (human)

J0598

Elaprase

idursulfase, 1mg

J1743

Erwinaze

injection, asparaginase Erwinia chrysanthemi, 1,000 I.U.

J9019

Fabrazyme

agalsidase beta

J0180

Faslodex

fulvestrant

J9395

Firazyr

injection, icatibant, 1mg

J1744

Firmagon

injection, degarelix, 1mg

J9155

Flolan

injection, epoprostenol, 0.5mg

J1325

Folotyn

pralatrexate

J9307

Glassia

alpha 1 proteinase, inhibitor (human), 10 mg

J0257

Halavan

injection, eribulin mesylate, 1mg

J9179

Hycamtin

injection , topotecan,0.1mg

J9351

 

oral, topotecan, 0.25mg

J8705

Ilaris

Injection, canakinumab, 1mg

J0638

Intravenous Immune Globulin (IVIG)

All IVIG requires prior authorization

 

Carimune/Carimune NF

Immune globulin, lyophilized (IVIG)

J1566

Flebogamma

Immune globulin, non-lyophilized (IVIG)

J1572

Gammagard/Gammagard SD

Immune globulin, lyophilized (IVIG)

J1566

Gammagard liquid injection

Immune globulin, non-lyophilized (IVIG), Gammagard liquid

J1569

Gammaplex

Immune globulin, non-lyophilized

J1557

Gammar-P

Immune globulin, lyophilized (IVIG)

J1566

Gamunex

Immune globulin, non-lyophilized (IVIG)

J1561

Hizentra

Immune globulin, (injection)

J1559

Immune Globulin NOS

Immune globulin, non-lyophilized (injection)

J1599

Iveegam EN

immune globulin, lyophilized (IVIG)

90283

Octegam

Immune globulin, non-lyophilized (IVIG)

J1568, 90283

Panglobulin/Panglobulin NF

Immune globulin, lyophilized (IVIG)

J1566

Privigen

Immune globulin, non-lyophilized (liquid) 500mg (IVIG)

90283, J1459

Euflexxa (effective 4/1/14) hyaluronan or derivative J7323
Gel-One (effective 4/1/14) hyaluronan or derivative J7326

Halavan

eribulin mesylate injection 0.1mg

J9179

Herceptin

Injection, Trastuzumab, 10mg

J9355

Hyalgan or Supartz (effective 4/1/14) hyaluronan or derivative J7321

Istodax

romidepsin

J9315

Ixempra

ixabepilone 1mg

J9207

Jetrea

ocriplasmin 0.125mg

J7316

Jevtana

cabazitaxel, injection, 1mg

J9043

Kadcyla

Ado-trastuzumab 1mg

C9131

Kalbitor

ecallantide

J1290

Krystexxa

injection, pegloticase 1mg

J2507

Kyprolis

injection, carfilzomib, 1mg

C9295

Makena

injection, hydroxyprogesterone caproate, 1 mg

J1725

Mozobil

injection, plerixafor 1mg

J2562

MyoBloc (Botulinum toxin type B)

MyoBloc (Botulinum toxin type B)

J0587

Myozyme

Lumizyme

alglucosidase Alpha, 10mg

J0220
J0221

Naglazyme

galsulfase

J1458

Natecor

nesiritide, 0.1mg

J2325

NPlate

injection, romiplostim, 10mcg

J2796

Nulojix

nesiritide 0.1mg

J0485

Oforta

injection, fludarabine phosphate, 50mg

J9185

Orencia

abatacept

J0129

Orthovisc (effective 4/1/14) hyaluronan or derivative J7324

Prolastin

Alpha 1-protenase inhibitor – human

J0256

Prolia

denosumab

J0897

Provenge

sipuleucel-T

Q2043

Radiesse

injectable filler

Q2026

Remicade

infliximab

J1745

Reclast

zoledronic acid, 1mng

J3489

Remodulin

tresprostinil,inhalation solution

J7686

Retisert

fluocinolone acetonide, intravitreal implant

J7311

Rituxan

rituximab

J9310

Sculptra

injectable filler

Q2027
C9800

Simponi

golimumab

J3590
C9399 (IV)

Simulect

baxiliximal

J0480

Solaris

eculizumab injection

J1300

Stelara

ustekinumab

J3357

Synribo omacetaxine mepesuccinate 0.01mg

C9297

Synvisc or Synvisc-One (effective 4/1/14) hyaluronan or derivative J7325

Temodar

injection, temozolomide, 1mg
oral, temozdomide, 5mg

J9328

J8700

Treanda

injection, bendamustine HCL, 1mg

J9033

Tysabri

natalizumab

J2323

Vectibix

panitumumab, 10mg

J9303

Velcade

bortezomib

J9041

Ventavis

iloprost, inhalation solution

Q4074

Vibativ

injection, telavancin 10 mg

J3095

Vidaza

azacitadine

J9025

Vpriv

velaglucerase alfa

J3385

Xeloda

 oral, capecitabine, 150mg
 oral, capecitabine, 500mg

J8520
J8521

Xeomin

incobotulinumtoxinA 1 unit

J0588

Xgeva

denosumab

J0897

Xiaflex

injection, collagenase clostridium histolyticum, 0.01 mg

J0775

Xolair

omalizumab

J2357

Yervoy 50ml/200ml

ipilimumab

J9228

Zemaira

Alpha 1-proteinase inhibitor - human

J0256

Zometa

zoledronic acid

Q2051, J3489

Zortress

oral, everolimus, 0.25mg

J7527

 

*Blue Cross of Idaho will review this drug to determine Medicare Part B versus Part D coverage. Drugs that are usually self-administered (defined as a drug that is self-administered more than 50 percent of the time) are excluded from Medicare medical coverage (Part B).