Obtain prior authorization for listed drugs

Prior authorization required for drugs listed on BCN/BCBSM program lists (e.g., Custom Drug List, Clinical Drug List, Custom Select, Lite PA, Preferred Therapy Program, Off‑Label/High‑Cost Specialty); most approvals are issued for a set period (commonly one year).

• Prior authorization must be obtained before coverage will be provided.
• Most approved prior authorizations last for a defined period (usually one year).

Submit oncology PA via OncoHealth/Availity

For oncology and supportive‑care drugs under the pharmacy benefit, submit prior authorization requests through the Oncology Value Management program (OncoHealth) via Availity; approvals are granted for at least 60 days and up to six months and off‑label uses must align with NCCN or other consensus guidelines.

• Use OncoHealth/Availity for electronic PA submission for oncology/supportive care drugs.
• If off‑label, include documentation showing consistency with NCCN or other consensus guidelines.

Document Adbry indication, prior trial, and no combined biologics

Adbry requests must document diagnosis of moderate‑to‑severe atopic dermatitis, age ≥12, prior trial and failure of a listed systemic or topical agent, and that Adbry will not be used with other biologics/targeted DMARDs for the same indication; initial approval is 6 months.

• Document age (≥12) and diagnosis of moderate‑to‑severe atopic dermatitis.
• Provide record of trial/failure of one listed therapy (e.g., high‑potency topical corticosteroid, tacrolimus, cyclosporine, methotrexate, azathioprine, mycophenolate).
• Confirm Adbry will not be combined with other biologics/targeted DMARDs.
• Initial authorization duration: 6 months.

Document NF1 diagnosis and Koselugo trial/failure

For NF1/plexiform neurofibroma therapies (e.g., Gomekli), prior authorization requires documentation of NF1 with symptomatic plexiform neurofibromas not amenable to complete resection, age ≥2 years, and trial/failure/intolerance/contraindication to Koselugo.

• Provide diagnosis of NF1 with symptomatic PN not amenable to complete resection.
• Document age (≥2 years) and prior trial and failure/intolerance/contraindication to Koselugo.

Provide CF diagnosis and responsive CFTR genetic test

Alyftrek PA requests must include CF diagnosis, age ≥6 years, genetic test confirming at least one CFTR variant responsive to Alyftrek, and confirmation it will not be used with other CFTR potentiators; initial approval is 1 year.

• Submit genetic test demonstrating a responsive CFTR variant.
• Confirm patient age ≥6 and that Alyftrek will not be combined with Trikafta, Orkambi, Kalydeco, or Symdeko.
• Initial approval duration: 1 year.

Document prior antiemetic trials for Akynzeo PA

Akynzeo coverage requires prior authorization documenting prevention of chemotherapy‑induced nausea/vomiting and prior trial of a generic 5‑HT3 antagonist and a preferred NK1 antagonist.

• Document prior trial of a generic 5‑HT3 antagonist (e.g., generic ondansetron).
• Document trial of a preferred NK1 antagonist when applicable.

Include HAE diagnostic labs and attack history for Andembry PA

For Andembry (HAE prophylaxis), prior authorization must include documented diagnosis with laboratory confirmation (low C4 and low C1‑INH antigenic or functional), history of ≥2 attacks/month or severe attacks, prescriber specialty (immunologist/allergist/hematologist), and statement that it will not be used with other HAE prophylaxis products; initial approval is 1 year and renewal requires ≥50% reduction in attack number or severity.

• Include lab results showing C4 below lab normal range and C1‑INH (antigenic or function) below normal.
• Document attack frequency (≥2 per month) or history of severe attacks (face, throat, GI).
• Confirm prescriber specialty and that Andembry will not be combined with other HAE prophylactics.
• Initial approval: 1 year; renewal: ≥50% reduction in attacks or severity.

Avoid combination biologic/targeted DMARD therapy (denial risk)

Do not approve combination use: many agents (examples: Arcalyst, Adbry, Cibinqo, Cimzia, Cosentyx, Dupixent) must not be used with other biologics or targeted DMARDs for the same indication — requests proposing concurrent biologic/DMARD therapy will be denied.

• If request proposes combination with another biologic/targeted DMARD for the same indication, do not approve and note denial risk.
• Ensure documentation states no concurrent biologic/targeted DMARD use.

Document prior topical therapy failures for Anzupgo PA

Anzupgo PA requires documentation of age ≥18, diagnosis of moderate‑to‑severe chronic hand eczema (≥3 months or ≥2 relapses in 12 months), trial and failure of a high‑ or super‑high‑potency topical corticosteroid and generic tacrolimus 0.1% ointment, and confirmation it will not be used with other JAK inhibitors or potent immunosuppressants; initial approval 1 year.

• Document disease duration/relapse history and prior topical therapy failures.
• Confirm no concomitant JAK inhibitors or potent immunosuppressants.
• Initial approval duration: 1 year.

Submit NPC diagnostic testing and neurologic findings for Aqneursa PA

For Aqneursa (NPC neurologic manifestations), prior authorization must include diagnostic confirmation (genetic/pathologic testing per criteria), age ≥18 or weight ≥15 kg, presence of neurologic manifestations, and confirmation it will not be used with other NPC medications except generic miglustat; initial approval is 1 year.

• Attach genetic testing showing biallelic pathogenic/likely pathogenic NPC1/NPC2 mutations or alternative diagnostic criteria (filipin or oxysterols) as specified.
• Document neurologic manifestations and patient age/weight.
• Confirm no concurrent NPC treatments except generic miglustat.

Provide genetic, transfusion history, and Reblozyl trial info for Aqvesme PA

Aqvesme PA requires genetic confirmation of α/β‑thalassemia, transfusion history and hemoglobin thresholds per transfusion‑dependent or non‑transfusion‑dependent pathways, and for β‑thalassemia document trial/failure/contraindication/intolerance to Reblozyl; initial approval 1 year.

• Provide genetic testing confirming α‑ or β‑thalassemia.
• For non‑transfusion dependent: document RBC units <5 in last 6 months and Hb <10 g/dL.
• For transfusion dependent: document ≥6 RBC units in last 6 months (or 100 mL/kg/year) and prior Reblozyl trial/failure for β‑thalassemia.

Provide indication‑specific evidence and prior trial data for Arcalyst PA

Arcalyst requests must include indication‑specific documentation (diagnosis, age/weight limits, genetic or lab evidence where required) and show prior trial/failure when indicated (e.g., Kineret or NSAID+colchicine for recurrent pericarditis); note Arcalyst must not be used with other biologics/targeted DMARDs.

• Attach diagnostic and laboratory/genetic evidence per the indication (CAPS, DIRA, recurrent pericarditis).
• Document prior trial/failure of Kineret or NSAID+colchicine when required.
• Confirm no concurrent biologics/targeted DMARDs for same indication.

Document MAC diagnosis and age for Arikayce PA

Arikayce PA must document MAC infection diagnosis and patient age ≥18; initial approval is 1 year.

• Provide microbiology/clinical evidence of MAC infection and patient age confirmation.
• Initial authorization duration: 1 year.

Document trials/failures of ≥3 antidepressants for Auvelity

Auvelity PA requires documentation of trials and failures of at least three antidepressant agents prior to coverage; initial approval is 1 year.

• List prior antidepressants tried, durations, and reason for failure/intolerance.
• Initial approval duration: 1 year.

Document tetrabenazine trial/failure for Austedo PA

Austedo PA requests must include diagnosis (chorea associated with Huntington's disease or tardive dyskinesia) and documentation of trial and failure/intolerance to tetrabenazine (Xenazine) when indicated; initial approval is 1 year.

• Provide diagnosis and prior tetrabenazine (Xenazine) trial/failure or rationale for not using tetrabenazine.
• Initial authorization duration: 1 year.

Provide serology/biopsy and prior immunosuppressive trials for Benlysta PA

Benlysta prior authorization requires age ≥5, SLE diagnosis with positive serology on two occasions, renal biopsy confirmation when lupus nephritis only, prior trials of at least two immunosuppressive agents (unless contraindicated), continuation of standard‑of‑care concomitant therapy, and not to be used with other biologics/B‑cell targeted therapies; initial approval is 1 year.

• Attach serology results (two separate positive tests) and renal biopsy if lupus nephritis is the only manifestation.
• Document prior immunosuppressive agent trials and ongoing standard‑of‑care therapies.
• Confirm no concurrent B‑cell targeted biologics.

Document prior pregnancy antiemetic trials for Bonjesta

Bonjesta PA for nausea/vomiting of pregnancy requires age ≥18 and documentation of trial/failure of doxylamine/pyridoxine combination and generic Diclegis prior to approval.

• Document prior trial and inadequate response to doxylamine/pyridoxine combination and to generic Diclegis.
• Confirm patient age ≥18.

Document PAH diagnosis and check formulary for bosentan

bosentan (Tracleer) PA for PAH requires documentation of pulmonary arterial hypertension (WHO Group 1); some formulations (suspension) may be marked NC on certain lists — check formulary flags.

• Provide diagnostic evidence supporting WHO Group 1 PAH.
• Verify program/formulary applicability and NC status for specific formulations (e.g., suspension).

Document imatinib and dasatinib trial/failure for bosutinib PA

bosutinib (Bosulif) PA requires documentation of Ph+ CML per phase and prior trial/failure or intolerance to imatinib and dasatinib.

• Provide CML phase documentation and evidence of imatinib and dasatinib trial and failure/intolerance.

Include Bronchitol tolerance test and CF use plan

Bronchitol PA requires documentation that it will be used as add‑on maintenance for CF, patient age ≥18, proof of passing the Bronchitol Tolerance Test, and instruction that a short‑acting bronchodilator be taken 5–15 minutes before each dose.

• Provide CF diagnosis and age confirmation (≥18).
• Include Bronchitol Tolerance Test result.
• Document plan to use short‑acting bronchodilator prior to dosing.

Document HCM severity, LVEF, LVOT gradient, and prior therapy for Camzyos PA

Camzyos PA must document symptomatic obstructive hypertrophic cardiomyopathy (NYHA II–III), age ≥18, LVEF >55%, LVOT peak gradient ≥50 mmHg, and trial/failure/intolerance to a non‑vasodilating beta blocker or nondihydropyridine CCB at maximally tolerated dose; renewal requires clinical benefit and LVEF ≥50%.

• Provide NYHA class, LVEF, and LVOT gradient measurements.
• Document trial/failure or intolerance to a non‑vasodilating beta blocker or nondihydropyridine CCB.

Provide biochemical/genetic confirmation for Cerdelga PA

Cerdelga PA requires biochemical assay confirmation of Gaucher disease type 1 and genotyping showing two pathogenic GBA mutations plus CYP2D6 genotyping; include clinical manifestations to support therapy.

• Attach enzymatic assay and genotyping results demonstrating two pathogenic GBA mutations.
• Include CYP2D6 genotyping and clinical symptom documentation.

Document long‑acting opioid trials and avoid concurrent long‑acting opioids for Belbuca PA

Belbuca PA requires documentation of moderate‑to‑severe chronic pain needing around‑the‑clock opioid analgesia and trial/failure/intolerance to two long‑acting opioids (one must be buprenorphine patch); concurrent multiple long‑acting opioids are not covered.

• Document prior trials/failures of two long‑acting opioids (one buprenorphine patch).
• Confirm patient is not on more than one long‑acting opioid concurrently.

Document required prior trials and obtain PA to avoid denial

Many listed drugs require prior authorization with diagnosis, age, and documented trial/failure of preferred or specified prior therapies; failure to document required prior trials or obtain PA may result in denial and member financial responsibility.

• Provide documentation of required prior trials, durations, and reasons for failure/intolerance.
• Obtain prior authorization before dispensing when listed; missing PA or unmet step therapy may lead to denial and member liability.

Document prior MS therapy failure for Cladribine PA

Cladribine prior authorization requires trial/failure or intolerance to one generic/preferred MS medication (examples provided); initial approval is 1 year and renewal requires clinical benefit.

• List prior MS medications tried and reason for failure/intolerance.
• Initial approval duration: 1 year; renewal requires evidence of benefit.

Include age, transfusional iron overload diagnosis, and prior chelation failure for deferiprone PA

Deferiprone PA requires patient age criteria (typically ≥8 years for initial criteria), diagnosis of transfusional iron overload due to thalassemia with inadequate chelation, and documentation of failure/intolerance to generic Jadenu or Exjade; initial approval is 1 year.

• Provide age and diagnosis documentation and prior chelation history.
• Document failure or intolerance to Jadenu or Exjade.

Provide HIV risk status and negative HIV test for Descovy (PrEP) PA/renewal

Descovy (PrEP) prior authorization requires that the member is high‑risk, not on concomitant antiretroviral therapy, and for renewal include a negative HIV test within the past 3 months.

• Document high‑risk indication and absence of concomitant ART.
• For renewals, attach negative HIV test within last 3 months.

Document platelet counts and prior therapy for Doptelet PA

Doptelet PA requires documentation of indication‑specific platelet thresholds and prior therapy failures where applicable; initial approval durations vary by indication (e.g., 60 days for chronic liver disease, 3 months for chronic ITP) and renewals require recent platelet counts and evidence of clinical benefit.

• Provide platelet counts and indication (chronic liver disease vs chronic ITP) with supporting labs.
• Attach documentation of prior therapies tried and responses as applicable.
• Note initial approval duration varies by indication.

Document indication, prior trials, corticosteroid taper plan, and no combined biologics for Dupixent PA

Dupixent requests must document indication‑specific criteria (age thresholds, diagnosis confirmation where required, prior trials/optimization of listed therapies, and when indicated a plan for use with a tapering course of oral corticosteroids); Dupixent must not be used in combination with other biologics/targeted DMARDs for the same indication. Initial approval for AD is 6 months; other indications commonly 1 year.

• Attach evidence of diagnosis and age eligibility (e.g., bullous pemphigoid: biopsy/serology; AFRS: history of sino‑nasal surgery and age ≥6).
• Document trials/failure of required prior agents (e.g., second‑generation antihistamine trial ≥2 months plus one additional agent) or note why age‑inappropriate.
• Provide a corticosteroid taper plan where required (e.g., bullous pemphigoid: prednisone taper until disease control).
• Confirm Dupixent will not be combined with other biologics/targeted DMARDs for the same indication.
• Initial approval: AD = 6 months; other indications often 1 year.

Document 2‑month second‑generation antihistamine trial and additional agent failure

Prior authorization requires documented trial and failure of a second‑generation antihistamine at maximal tolerated dose for ≥2 months plus trial/failure of one additional agent from a specified list (H2 antagonist, leukotriene receptor antagonist, first‑generation antihistamine at bedtime, hydroxyzine or doxepin when age‑appropriate); failure to document these trials may trigger denial.

• Provide dates, dosages, and outcomes for second‑generation antihistamine trial (≥2 months).
• Document trial and inadequate response to one additional listed agent at maximal dosing.

Provide biopsy/serology and corticosteroid taper plan for bullous pemphigoid PA

For bullous pemphigoid, PA must include diagnosis confirmation by skin biopsy or serology, patient age ≥18, and a documented plan to use Dupixent in combination with a tapering course of oral corticosteroids (e.g., prednisone) until disease control; absence of biopsy/serology or steroid plan may result in denial.

• Attach skin biopsy or serology confirming bullous pemphigoid.
• Document age (≥18) and a corticosteroid taper plan (e.g., prednisone course until disease control).
• Failure to provide biopsy/serology or taper plan is a denial trigger.

Document failure of listed alternative therapies before specialty biologics

Prior authorization routinely requires documentation of trials and failure of at least one alternative therapy (examples include another second‑generation antihistamine, H2 antagonist, leukotriene receptor antagonist, first‑generation antihistamine at bedtime, hydroxyzine or doxepin when age‑appropriate); lack of these documented trials increases denial risk.

• List prior alternatives tried with durations and failure reasons.
• Ensure maximal dosing trials are documented where required.

Request appropriate initial approval duration (AD = 6 months; others commonly 1 year)

Initial authorization durations: atopic dermatitis approvals are commonly 6 months; many other specialty agents have initial approvals of 1 year — include the requested initial approval period in the PA.

• Specify initial approval duration requested (AD = 6 months; many others = 1 year).
• Provide supporting documentation for duration selection.

Document required step therapy trials and Preferred Therapy Program conditions

When a therapy is subject to step therapy, document trials of preferred, clinically sound, cost‑effective drugs (often generics or preferred formulary agents) before requesting non‑preferred/brand alternatives; Preferred Therapy Program may require the brand not be filled in the last 180 days to qualify.

• Provide medication history showing trials of preferred/generic agents and dates.
• If relying on Preferred Therapy Program, confirm no brand fill in prior 180 days when applicable.

Document generic stimulant trials or swallow‑inability for Adzenys ER PA

Adzenys ER PA (ADHD) requires documentation of age ≥6 and treatment failure or intolerance to both a generic methylphenidate and a generic amphetamine product (one must be long‑acting), or documentation that the patient cannot swallow tablets/capsules and failed sprinkle options.

• Document trials and failures of a generic methylphenidate and a generic amphetamine (one long‑acting).
• If inability to swallow is claimed, provide evidence and prior attempt of sprinkle agent.

Document trials of two generic triptans before almotriptan approval

Almotriptan (Axert) step therapy requires trial of two generic triptans (examples: sumatriptan/Imitrex, rizatriptan/Maxalt, naratriptan/Amerge, zolmitriptan/Zomig) prior to approval; document those trials.

• Provide dates and outcomes for trials of two different generic triptans.
• Initial approval commonly 1 year.

Document sequential biologic/DMARD trials per step therapy lists

Multiple biologics require sequential trials of preferred biologics/DMARDs (lists vary by indication — e.g., Cimzia/Cosentyx require documented failure of specified biosimilars/agents); include exact prior biologic/DMARD trial dates, doses, and reasons for failure/intolerance.

• List each biologic/DMARD trial with dates, dosing, and clinical response or intolerance.
• Where biosimilar preference is listed, indicate use of preferred biosimilar when applicable.

Document NSAID trials and ensure no concurrent oral NSAIDs for topical diclofenac

For certain topical/oral products (e.g., diclofenac 2% external solution), PA requires prior trials of generic oral/topical NSAIDs and Pennsaid; coverage will not be provided if the member is on concurrent oral NSAIDs.

• Document trials/intolerance to generic oral diclofenac and at least two other oral NSAIDs and trial of Pennsaid 1.5% topical.
• Confirm there is no concurrent oral NSAID therapy at time of request.

Submit oncology PA with FDA/NCCN alignment via OncoHealth/Availity

Oncology PA submissions must be sent through OncoHealth via Availity and include documentation that use is consistent with FDA labeling or, for off‑label uses, NCCN/consensus guidelines; approvals range from 60 days up to six months.

• Use Availity to submit oncology/supportive care PA requests to OncoHealth.
• Include evidence of guideline‑consistent use (FDA or NCCN/consensus) for off‑label indications.

Include prior trials, indication, and safety/abuse info in PA

Providers must document prior trials of preferred alternatives (per step therapy rules), indication, and any safety/abuse considerations in the PA; absence of this supporting clinical documentation is a common denial trigger.

• Include medication history showing prior trials and failures, pertinent diagnoses, and safety/abuse risk notes.
• Missing prior trial documentation or missing PA are grounds for denial.

Submit factor levels, inhibitor titers, bleed history, and treatment center info for hemophilia PA

For hemophilia agents (e.g., Alhemo), include factor levels, inhibitor titers (Bethesda Units/mL), number of bleeds in the past 12 months, documentation of prior prophylactic factor therapy effectiveness, and that prescriptions are by specialists at accredited hemophilia treatment centers.

• Provide factor VIII level and inhibitor titer (>5 BU/mL when applicable) and bleed history in last 12 months.
• Confirm specialist prescriber and dispensing at an accredited hemophilia treatment center.
• Document trial/failure or intolerance to Hemlibra when required.

Provide C4/C1‑INH labs and attack history for HAE agents

HAE documentation: include laboratory confirmation (C4 below lab normal range and C1‑INH antigenic or functional below lab normal), documentation of attack frequency/severity, prescriber specialty, and confirmation the agent won’t be used with other HAE prophylaxis products; failure to include labs or attack history may cause denial.

• Attach lab reports showing C4 and C1‑INH results per lab reference ranges.
• Document attack frequency (≥2/month) or history of severe attacks and prescriber specialty.
• Confirm no concurrent HAE prophylaxis products.

Provide attack‑reduction data (≥50%) for HAE renewals

For Dawnzera (HAE) renewal, include documentation demonstrating improvement (≥50% reduction in number or severity of attacks) and recent attack counts in prior 6 months; for Andembry renewal likewise show ≥50% reduction.

• Submit attack counts for the prior 6 months and documentation showing ≥50% reduction in attacks or severity.
• Include treatment start/response timeline.

Avoid concurrent sedative hypnotics or concurrent HAE prophylaxis (denial risk)

Dawnzera and Dayvigo: Dayvigo will not be approved for combination therapy with other sedative hypnotics — propose no concurrent sedative hypnotic use; Dawnzera and other HAE agents must not be used with other HAE prophylaxis products.

• Confirm no concurrent sedative hypnotics when requesting Dayvigo.
• Confirm no concurrent HAE prophylaxis products for Dawnzera.

Include age and prior chelation failure for deferiprone PA

Deferiprone PA: include patient age (≥8 years per initial criteria or noted alternate age entries), transfusional iron overload diagnosis, and failed/intolerant chelation history (Jadenu/Exjade); initial approval 1 year and renewal requires clinical benefit.

• Provide age and documentation of inadequate response to Jadenu or Exjade.
• Initial approval duration: 1 year; renewal requires evidence of benefit.

Include recent negative HIV test for Descovy renewal

Descovy (PrEP) renewals must include a negative HIV test within the past 3 months; initial approval is 2 years for high‑risk members not on ART.

• Attach negative HIV test within 3 months for renewal requests.
• Document high‑risk status and no concomitant ART for initial PA.

Attach age, biopsy/serology, sino‑nasal surgery history, and prior trial records for Dupixent PA

Required supporting documentation for Dupixent and related indications: include patient age, diagnosis confirmation (e.g., skin biopsy or serology for bullous pemphigoid), history of sino‑nasal surgery for AFRS, and records of prior trials/failures of listed adjunctive agents (second‑generation antihistamine ≥2 months plus an additional agent).

• Attach biopsy/serology for bullous pemphigoid and operative history for AFRS.
• Provide prior medication trial records (second‑generation antihistamine ≥2 months and one additional listed agent).

Provide complete supporting clinical documentation to avoid denial

Supporting clinical documentation must confirm diagnosis (e.g., biopsy/serology for bullous pemphigoid), prior trials of required agents, and a plan for adjunctive therapy where required (e.g., corticosteroid taper for bullous pemphigoid); missing these items may trigger denial.

• Provide concrete prior trial dates/doses and objective diagnostic test results.
• Include corticosteroid taper plan when policy requires combination therapy.

Document sino‑nasal surgery history and age ≥6 for AFRS PA

For AFRS, required documentation includes patient age (≥6 years) and a history of sino‑nasal surgery; absence of surgical history or age documentation may result in denial.

• Attach operative report or clinical documentation of prior sino‑nasal surgery.
• Verify patient age (≥6 years) for AFRS pathway.

Attach all required diagnostic tests and prior trial records to avoid NC/denial

When required clinical documentation (e.g., biopsy/serology for bullous pemphigoid, sino‑nasal surgery for AFRS, lab confirmation for HAE) is missing, requests are at high risk of denial or being marked NC; providers should ensure all required tests and records are attached.

• Check that diagnostic tests and prior trial documentation are included before submission.
• Incomplete documentation commonly triggers denials or Not Covered (NC) designations.

Avoid common denial triggers: missing PA, unmet steps, missing diagnostics, or concurrent biologics

Denial triggers include missing prior authorization or unmet step therapy requirements (documented trials and failures of required agents), missing diagnostic confirmation (e.g., biopsy/serology for bullous pemphigoid), absence of required steroid taper plan, or proposing concurrent biologic/DMARD therapy for the same indication.

• Obtain required PA and document step therapy trials/failures.
• Attach required diagnostic confirmation and corticosteroid taper plans where indicated.
• Do not request concurrent biologic/targeted DMARD use for the same indication.

adalimumab — required prior agent (biosimilar)

Preferred adalimumab biosimilar is listed as a required prior agent in multiple biologic step‑therapy sequences; document trials of preferred biosimilars where required before requesting alternative biologics.

ustekinumab — preferred biosimilar prior trial

Preferred ustekinumab biosimilar appears among required prior‑therapy lists for psoriasis/psoriatic disease; include documentation of prior trial of preferred ustekinumab biosimilar when applicable.