Prior authorization is a utilization management program that encourages appropriate drug use to assist in reducing drug benefit costs for everyone. The prescription drug card program includes a prior authorization program for the following drugs:
COX-2 Drugs
The COX-2 drugs, currently Celebrex, are
in a class of drugs known as nonsteroidal anti-inflammatory drugs (NSAIDs). This class also includes ibuprofen, naproxen and diclofenac, among
others.
Requires a prior authorization request.
Xolair
Xolair is used for patients, 12 years and older, with moderate to
severe persistent asthma. In addition, the patient must have an allergy
to a perennial airborne allergen as confirmed by skin testing. Other
drug therapies would be used before Xolair would be appropriate. Patients
should talk with their doctor about the steps to take to control asthma.
Requires a prior authorization
request.
Growth Hormone - More about Growth Hormones
If you have questions or wish to initiate a request for prior authorization, please contact Customer Service toll-free at (800) 432-3990.
OxyContin
OxyContin is a controlled-release tablet for the management of moderate
to severe pain when a continuous, around-the-clock analgesic is needed
for an extended period of time.
Requires a prior authorization
request only when dose exceeds two per day.
Synagis - More about Synagis
Synagis is indicated for the prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients at high risk.
Members: If you have questions or wish to initiate a request for prior authorization, please contact your doctor.
Health care providers: If your practice purchases Synagis and bills BCBSKS, please use this prior authorization request. If Synagis will be ordered and shipped from the BCBSKS preferred pharmacy vendor, Triessent, please use this prior authorization request.
High Blood Pressure - more information
Many different drugs are used to treat high blood pressure. One class of drugs is called ACE Inhibitors. There are many generic ACE Inhibitors available. Medical guidelines support using one of the generic drugs before using a brand-name ACE Inhibitor or a class of drugs called ARBs. Use of a brand-name ACE Inhibitor or ARB, before trying a generic, requires a prior authorization request.
Depression - more information
Many different drugs are used to treat depression. Medical guidelines support using one of the generic drugs available before using a brand-name antidepressant drug. Use of a brand-name antidepressant, before trying a generic, requires a prior authorization request.
Specific guidelines, developed and approved by practicing physicians, have to be met for the drugs requiring PA to be approved and covered under the member's prescription drug benefits. If the PA is approved, the member's copayment will be determined by his or her prescription drug benefit. If that requirement is not met, the member may purchase the drug, but the cost will not be reimbursed by BCBSKS. Affected drugs will be marked with PA on the member's Preferred Medication List and may change quarterly.