CurrentBlue Cross Blue Shield - IowaPolicy N/A

FEP Medical Prior Authorization Drug List

List of medical-benefit drugs subject to prior authorization for the Blue Cross and Blue Shield Federal Employee Program (FEP), reviewed through Novologix. The document enumerates drugs (by brand and generic names) and therapeutic classes that require prior authorization; it refers readers to the FEP Medical Policy Manual for applicable clinical criteria.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyFEP Medical Prior Authorization Drug List

Policy CodePolicy N/A

Change TypeIndex / Listing

Effective Date

Next Review Date

Key ActionAny drug listed must be submitted and reviewed through Novologix; follow Novologix submission procedures and refer to the FEP Medical Policy Manual for specific clinical criteria.

POLICY UPDATE CHANGES

No material clinical or coverage changes — the brief is an index-style list and does not describe any policy changes.

~260Drugs listed

AllPrior authorization via Novologix

Coverage Summary

Scope: Index-style list of medical-benefit drugs subject to prior authorization for the Blue Cross and Blue Shield Federal Employee Program (FEP) that are reviewed through Novologix. The list enumerates drugs by brand, generic, and therapeutic class. Status: CURRENT. For specific clinical criteria, refer to the FEP Medical Policy Manual.

Prior Authorization Requirement

Listed drugs require prior authorization through Novologix; refer to FEP Medical Policy Manual for specific clinical criteria.

Prior Authorization Requirement: Drug is included on the FEP Medical Prior Authorization Drug List and therefore requires prior authorization via Novologix

Applicable Codes (Drugs Requiring Prior Authorization)

Drugs requiring prior authorization (by brand, generic, therapeutic class)mixed

SandoSTATIN LAR Depot	Octreotide Acetate — Acromegaly
Signifor LAR	Pasireotide Pamoate — Acromegaly
Aralast NP	Alpha1-Proteinase Inhibitor (human) — Alpha-1 Antitrypsin Deficiency
Glassia	Alpha1-Proteinase Inhibitor (human) — Alpha-1 Antitrypsin Deficiency
Prolastin-C	Alpha1-Proteinase Inhibitor (human) — Alpha-1 Antitrypsin Deficiency
Zemaira	Alpha1-Proteinase Inhibitor (human) — Alpha-1 Antitrypsin Deficiency
Amvuttra	Vutrisiran Sodium — Amyloidosis
Onpattro	Patisiran Sodium — Amyloidosis
Tegsedi	Inotersen Sodium — Amyloidosis
Procrit	Epoetin Alfa — Anemia

1–10 of 147

1/15

Provider Actions and Operational Requirements

Prior Authorization

Prior authorization required via Novologix

Any drug listed in this FEP Medical Prior Authorization Drug List must be submitted and reviewed through Novologix; providers must follow Novologix submission procedures and refer to the FEP Medical Policy Manual for specific clinical criteria.

All listed drugs require submission through Novologix

Documentation Required

Refer to FEP Medical Policy Manual for criteria

Clinical eligibility and medical necessity criteria for listed drugs are governed by the FEP Medical Policy Manual; providers must supply documentation as required by those policies during prior authorization review.

Background & Definitions

Background: This document is an index-style list enumerating medical-benefit drugs that have authorization requirements under the FEP program and are processed through Novologix; it does not contain the clinical criteria themselves but directs readers to the FEP Medical Policy Manual for authorization criteria.

Definitions:

• Novologix: External prior authorization review vendor used by FEP to process medical benefit drug authorizations.

• FEP Medical Policy Manual: Source document containing clinical criteria and medical necessity guidance referenced for each drug.

Clinical Evidence / Criteria Source

This document does not include clinical eligibility criteria or primary evidentiary guidance. Clinical eligibility and medical necessity criteria for drugs listed here are contained in the FEP Medical Policy Manual, which should be referenced for authorization requirements and documentation expectations.