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:
Ampyra (dalfampridine)
Ampyra (dalfampridine) is an oral medication that is FDA-approved to improve walking distance (measured as walking speed) in patients with multiple sclerosis (MS). The intent of this program is to ensure the appropriate selection of patients for optimal therapeutic response and reduced risk of adverse events.
Requires a prior authorization request.
See the BCBSKS medical policy.
Antidepressant Agents - more information
Many different medications are used to treat depression. Medical guidelines support using a generic antidepressant medication before a brand-name product. Use of a brand-name antidepressant, before trying a generic, requires a prior authorization request.
See the BCBSKS medical policy.
Antihypertensives (drugs to treat high blood pressure) - more information
There are many medication options available to treat high blood pressure. Some common classes include the angiotensin converting enzyme inhibitors (ACE Inhibitor), angiotensin-II receptor blockers (ARB) and the renin inhibitors (RI). The ACE Inhibitor and ARB classes contain generic products that are proven safe and effective in treating high blood pressure. Medical guidelines support using one of the generic drugs before using a brand-name ACE Inhibitor, ARB, or RI. Use of a brand-name product before trying a generic, requires a prior authorization request.
See the BCBSKS medical policy.
Biologic Immunomodulators
Products included in the Biologic Immunomodulator program are used to treat conditions such as rheumatoid arthritis, Crohn’s Disease, psoriasis and other inflammatory joint and skin conditions. The intent of this program is to encourage the use of first-line conventional agents, some of which are available as generics (for example, methotrexate for rheumatoid arthritis) and use of a preferred biologic product before the nonpreferred agents. The preferred biologic agent is Humira and the nonpreferred biologic agents include Amevive, Cimzia, Enbrel, Kineret, Simponi and Stelara (when dispensed by a pharmacy). Infused or injectable products covered under the medical benefit are not affected by this program. Use of a nonpreferred product before preferred product requires a prior authorization request.
See the BCBSKS medical policy.
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.
See the BCBSKS medical policy.
Growth Hormone
Growth Hormone for pediatric and adult therapy may be covered under the terms of your contract. Growth Hormone requires a prior authorization request. Omnitrope preferred - Members approved for growth hormone therapy will be required to use our preferred growth hormone product, Omnitrope. All brands of growth hormone contain somatropin. Prices vary widely. A preferred drug is chosen based on safety, efficacy, uniqueness and cost. Omnitrope has been selected as our preferred growth hormone because it will significantly reduce the cost of this therapy compared to other growth hormone medications. There is a prior authorization process to allow other brands of somatropin after a trial and treatment failure of Omnitrope.
Requires a prior authorization
request.
See the BCBSKS medical policies for Adult Growth Hormone and Pediatric Growth Hormone.
Hepatitis
Treatment of Hepatitis C now uses three different types of medications:
Using these three unique therapies improves the cure rate for Hepatitis C, but it also creates a complex treatment program. To help ensure appropriate length of therapy, patient adherence and coverage, prior authorization is required for Pegasys (preferred product) and Peg-Intron as well as Incivek and Victrelis. Members who are currently using these products will be allowed to continue therapy without completing the prior authorization process.
Requires a prior authorization request for Pegasys or Peg-Intron.
Requires a prior authorization request for Incivek or Victrelis.
See the BCBSKS medical policy for Hepatitis B / Hepatitis C Agents.
Multiple Sclerosis-Interferon Drugs
There are four interferon products (Avonex, Betaseron, Extavia and Rebif) used in the treatment of multiple sclerosis, none showing clinical superiority over another. The preferred products are Betaseron and Rebif, and members must try and fail one of these products (or seek approval through the prior authorization (PA) process) before starting therapy with Avonex or Extavia. Members who are currently using Avonex or Extavia will be allowed to continue therapy without completing the PA process.
Requires a prior authorization request.
See the BCBSKS medical policy for Multiple Sclerosis Interferon Agents.
Oral Oncology Drugs
This class of drugs includes certain oral medications used in the treatment of various forms of cancer. The intent of this program is to ensure the appropriate selection of patients for treatment according to product labeling and/or clinical studies and guidelines. Products that require prior authorization include Afinitor, Caprelsa, Gleevec, Hexalen, Hycamtin, Lysodren, Matulane, Nexavar, Oforta, Sprycel, Sutent, Tarceva, Tasigna, Targretin, Temodar, Tretinoin (oral), Tykerb, Votrient, Xalkori, Xeloda, Zelboraf, Zolinza, Zytiga.
Requires a prior authorization
request.
See the BCBSKS medical policy.
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 the daily quantity limit is exceeded.
Statin Drugs for Treatment of High Blood Cholesterol - More about Statin Drugs
There are a number of brand and generic drugs used to treat high blood cholesterol. You may be required to use a generic statin drug prior to having coverage for a brand statin drug. Brand drugs may require a prior authorization request.
See the BCBSKS medical policy.
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.
See the BCBSKS medical policy.
Note to Providers: If your patient's prescription drug coverage is with a carrier other than BCBSKS/Prime Therapeutics (including employees of the State of Kansas and their dependents), please contact that drug carrier for information about Synagis coverage and any applicable process to obtain prior authorization.
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.
See the BCBSKS medical policy.
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.