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Medical Policies

5.0 Prescription Drug

5.01 Prescription Drugs Introduction 
Medically
Necessary
and
Investigational
For Blue Cross of Idaho`s definition of medically necessary and investigational, please click here. 
5.01.01 Guidelines for Prior Authorization of Pharmacologic Therapies
5.01.04 Erythropoiesis- Stimulating Agents (ESAs)
5.01.05 Botulinum Toxin 
5.01.06 Human Growth Hormone
5.01.07  Acute and Maintenance Tocolysis 
5.01.08 Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
5.01.09 Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension
5.01.10 Immune Prophylaxis for Respiratory Syncytial Virus
5.01.12 Trastuzumab 
5.01.15 Infliximab
5.01.16 Intravenous Anesthetics for the Management of Chronic Pain
5.01.17 Repository Corticotropin Injection
5.01.18 Bevacizumab in Advanced Adenocarcinoma of the Pancreas
5.01.19  Injectable Clostridial Collagenase for Firbroproliferative Disorders 
5.01.20 Pertuzumab for Treatment of HER-2 Positive Malignancies
5.01.21 Newer Anticoagulant medications
05.01.22 Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies
5.01.93  Specialty Drugs
5.01.95  Xolair (Omalizumab) 
5.01.96  Therapeutically Generic Override  
5.01.97  Tysabri (natalizumab) 
5.01.99 Treatment of Arthropathies with Biologic-Response Modifiers
5.01.100 Treatment of Inflammatory Bowel Diseases with Biologic-Response Modifiers
5.01.101 Enzyme-replacement Therapy for Lysosomal Storage Disorders 
5.01.102 Sunitinib (Sutent®)
5.01.105  IV Iron Therapy 
5.01.108 Pharmacological Treatment of Hereditary Angioedema
5.01.109  Implantable Hormone Pellets 
5.01.110  Belimumab (Benlysta®) 
5.01.111 Eculizumab (Soliris)
5.01.112 Use of Sodium Oxybate (Xyrem®)