Prior Authorization

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.

Androgens and Anabolic Steroids
These drugs are commonly referred to as testosterone. Drugs are approved for members who need replacement therapy and for use that is medically necessary for certain conditions. The preferred topical drugs, Androderm and Androgel, must be used before a non-preferred topical (Axiron, Bio-T-Gel, Fortesta, Striant, Testim, First-Testosterone). Quantity limits will apply to the topical and injectable drugs (Delatestryl, Depo-Testosterone, Testopel). Prior Authorization applies to all brand and generic products.
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 both preferred biologic products before the nonpreferred agents. The preferred biologic agents are Humira and Enbrel and the nonpreferred biologic agents include Amevive, Cimzia, Kineret, Orencia subcutaneous injection, Simponi, Stelara (when dispensed by a pharmacy) and Xeljanz. 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.

Denosumab (Prolia and Xgeva)
Denosumab (Prolia and Xgeva) is a subcutaneous injection that is FDA approved for treatment of postmenopausal women with osteoporosis at high risk for fracture, treatment to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy for nonmetastatic prostate cancer, treatment to increase bone mass in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer, prevention of skeletal-related events in patients with bone metastases from solid tumors.
Requires a prior authorization request.
See the BCBSKS medical policy.

Diabetic Blood Sugar Test Strip/Disc
The Diabetic Blood Sugar Test Strip/Disc program encourages the use of cost-effective preferred test strips/discs, Bayer CONTOUR®, Bayer CONTOUR® NEXT EZ, Bayer BREEZE® 2 and ACCU-CHEK® Nano SmartView (Roche), ACCU-CHEK® Aviva Plus (Roche), before the more expensive nonpreferred products. The prior authorization process will accommodate for the use of nonpreferred test strips/discs when the preferred products cannot be used due to patient inability to use them accurately, or special requirements such as an insulin pump (not accommodated with a preferred glucose test strip/disc or meter), visual impairment, or other physical or mental disability.
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 Human Growth Hormone.

Hepatitis
Treatment of Hepatitis C now uses three different types of medications:

  • Pegasys or Peg-Intron
  • Ribavirin
  • Incivek or Victrelis

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.

HP Acthar Gel
HP Acthar Gel is an intramuscular injection to treat infantile spasms in patients less than twenty-four months of age. The intent of the program is to ensure the patient is appropriate for therapy and the dose is within the FDA labeled dosing.
Requires a prior authorization request.
See the BCBSKS medical policy for HP Acthar Gel.

Intra-articular Hyaluronan Injections for Osteoarthritis
Injections will be approved for treatment of painful osteoarthritis of the knee in patients who have insufficient pain relief from conservative non-drug therapy and simple analgesic pain relievers. Repeated courses of intra-articular hyaluronan injections of the knee may be considered medically necessary if significant pain relief was achieved with the prior course of injections and at least 6 months have passed since completion of the prior course. Injections in joints other than the knee are considered experimental / investigational and will not be covered. Use of a nonpreferred agent will only be allowed after a treatment failure with a preferred agent.
Requires a prior authorization request.
See the BCBSKS medical policy for Intra-articular Hyaluronan Injections for Osteoarthritis.

Kalydeco™ (ivacaftor)
Kalydeco is an oral tablet to treat cystic fibrosis in patients 6 years of age and older who have G551D mutation in the CFTR gene. If the patient's genotype is unknown, an FDA-cleared mutation test should be used to detect the presence of the G551D mutation. Approved doses will be at or below the maximum FDA labeled dose.
Requires a prior authorization request.
See the BCBSKS medical policy for Kalydeco (ivacaftor).

Multiple Sclerosis Agents
Drugs to treat multiple sclerosis (Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Rebif, Tecfidera, Tysabri) will be approved for therapy that meets product labeling and/or clinical guidelines and/or clinical studies. Two of the preferred agents, Betaseron, Rebif, Tecfidera and Copaxone must be tried first, or members may seek approval for a non-preferred agent through the prior authorization (PA) process. Only one of these drugs may be used at a time to reduce the risk of developing serious adverse effects.
Requires a prior authorization request for Multiple Sclerosis Agents (Non-Tysabri).
Requires a prior authorization request for Tysabri.
See the BCBSKS medical policy for Multiple Sclerosis Agents.
See the BCBSKS medical policy for Tysabri.

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.
See the BCBSKS medical policy for OxyContin

Self Administered Oncology Drugs
This class of drugs includes certain self administered 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. New products are continuously becoming available and may be added to the prior authorization list. For the most current list of drugs requiring prior authorization, please refer to the BCBSKS medical policy.
Requires a prior authorization request.
See the BCBSKS medical policy.

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, or if Synagis will be ordered and shipped from the BCBSKS preferred pharmacy vendor, Prime Specialty Pharmacy, 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.