Prior Authorization list for non-formulary and formulary drugs
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This document lists medications (by drug/group) that may require prior authorization (PA) and indicates where PA forms should be submitted; it applies to Blue Cross Blue Shield - Kansas members and providers seeking PA information. Coverage/PA requirements may vary by plan and should be verified for individual members.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria and Drug List
General coverage stance
The following describes the plan-level stance for prior authorization (PA) in this listing.
Enumerated PA drug list and submission locations
The drugs and drug groups below require prior authorization; the designated submission location for PA requests is shown with each entry.
Examples (not exhaustive)
- Ilaris — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Ilumya — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Imfinzi — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Infliximab (Remicade, Renflexis) — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Injectafer — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Insulin Combination Agents (Soliqua, Xultophy) — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- Insulin Pump (Omnipod products, V-Go) — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- Interleukin agents (e.g., Dupixent, Arcalyst) — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- IVIG/SCIG products (Alyglo, Asceniv, Cutaquig, Gammaplex, etc.) — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Long-acting granulocyte colony stimulating factors (Fulphila, Nyvepria, etc.) — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Long-acting insulin (insulin degludec, insulin glargine, Rezvoglar) — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- Self-Administered Oncology Agents (extensive oral agents list) — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- Spevigo (IV/SQ), Spinraza, Strensiq, Substrate Reduction Therapy agents — Where to submit PA form = Prime Therapeutics (Gateway PA or Cover My Meds) as specified.
- Many specialty oncology and biologic agents (Sustol, Susvimo, Synagis, Tecartus, Tecelra, etc.) — Where to submit PA form = Prime Therapeutics/Gateway PA or Cover My Meds per listing.
List of drugs requiring prior authorization (administrative list)
Additional listed drugs require prior authorization; each entry in the administrative list specifies the submission portal for PA requests.
Selected administrative entries
- Spevigo IV/SQ — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Spinraza — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Statin products (Altoprev, Zypitamag, etc.) — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- Strensiq — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- Substrate Reduction Therapy (Cerdelga, Opfolda, Zavesca) — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- Sucraid, Sunosi — Where to submit PA form = Prime Therapeutics/Cover My Meds.
- Sustol, Susvimo, Syfovre, Synagis, Takhzyro, Talvey, Tavneos, Tecartus, Tecelra — Where to submit PA form = Prime Therapeutics/Gateway PA or Cover My Meds per listing.
- Tecentriq (IV and Hybreza), Tecvayli, Tepezza, Tezspire, Tivdak, Tocilizumab — Where to submit PA form = Prime Therapeutics/Gateway PA.
- Topical Doxepin, Topiramate ER, Trastuzumab IV, Tremfya, Trodelvy, Ultomiris — Where to submit PA form = Prime Therapeutics (Gateway PA or Cover My Meds) as specified.
- Uplizna, Ustekinumab, Vabysmo, VPRIV, Vyepti, Vectibix, Vimizim, Voydeya, Vyvgart — Where to submit PA form = Prime Therapeutics (Gateway PA or Cover My Meds) or BCBSKS when specified.
Codes and Device/Drug Group Listings
| Continuous Glucose Monitoring (PA required under pharmacy benefit) — Dexcom G6 CGM System; Dexcom G7 CGM System; Eversense; Eversense 365; Eversense e3; Freestyle Libre; Freestyle Libre 2; Freestyle Libre 3; Guardian 4; Medtronic Instinct sensors; Medtronic MiniMed Guardian Connect System; Simplera Sync. | |
| Corticotropin — Purified Cotrphin Gel. | |
| Corticotropin-ACTH — Acthar Gel; Cortrophin Gel. | |
| Cosentyx — Cosentyx. | |
| Crenessity — Crenessity. | |
| Crysvita — Crysvita. | |
| Ctexli — Ctexli. | |
| Cyramza — Cyramza. |
| Self-Administered Oncology Agents — examples include abiraterone, Afinitor, Afinitor Disperz, and an extensive list of oral oncology agents requiring prior authorization; PA submission via Prime Therapeutics/Cover My Meds or Prime Therapeutics/Gateway PA as specified. |
| No codes listed |
Provider Submission Instructions and Actions
How to verify PA requirements
Verify prior authorization (PA) requirements before prescribing or dispensing. To confirm coverage, benefits, or whether a PA is required for a specific member, call Blue Cross Blue Shield of Kansas Provider Services: In Topeka: 785-291-7000; In Kansas: 800-432-0216; or send an electronic inquiry through your established connection with your local Blue Plan. Electronic PA submissions are routed either to Prime Therapeutics (Gateway PA) or via CoverMyMeds depending on the medication — see drug-specific entries below for the correct submission pathway.
- Call to verify coverage and PA requirements: In Topeka: 785-291-7000; In Kansas: 800-432-0216
- Electronic inquiries: send via your established connection with your local Blue Plan
- PA submission destinations: Prime Therapeutics (Gateway PA) or CoverMyMeds — check drug-specific routing
Drug-specific PA requirements and submission location
Certain drugs and product classes have specific PA requirements and designated submission destinations. Submit PA forms to Prime Therapeutics (Gateway PA) or to CoverMyMeds as noted. Some products are exceptions and must be submitted directly to BCBSKS — these are called out in the BCBSKS exceptions entry.
- Examples of drug-specific PA routing: Ilaris, Ilumya, Imfinzi, Influximab (Remicade, Renflexis), Injectafer, Imjudo — submit to Prime Therapeutics/Gateway PA
- Insulin combination agents (Soliqua, Xultophy) and insulin pumps (Omnipod family, V-Go) — submit to Prime Therapeutics/Cover My Meds
- Interleukin agents (e.g., Arcalyst, Dupixent, Adbry, Nemluvio) — submit to Prime Therapeutics/Cover My Meds
PA submission pathways for ambulatory agents
Ambulatory agents and device-related products follow designated PA submission pathways. Use the stated pathway for timely processing.
- Insulin combination agents (Soliqua, Xultophy): Prime Therapeutics/Cover My Meds
- Insulin pumps (Omnipod, Omnipod DASH, Omnipod GO, Omnipod 5 G6, V-Go): Prime Therapeutics/Cover My Meds
- Interstitial lung disease agents (Esbriet, Ofev, pirfenidone): Prime Therapeutics/Cover My Meds
BCBSKS submission exceptions
Some products are exceptions and require PA forms to be submitted directly to Blue Cross Blue Shield of Kansas (BCBSKS) rather than to Prime Therapeutics or CoverMyMeds. Verify submission destination prior to sending the PA.
- BCBSKS submission examples: Itvisma, Kebilidi, Luxturna, Lyfgenia, Vyjuvek
Specialty biologics and supportive agents PA
Specialty biologics and supportive agents (including long-acting G-CSF, long-acting insulins, SCIG/IVIG, enzyme replacement therapies, and similar specialty biologics) generally require PA and have specific routing instructions. Check the drug entry for the correct submission destination.
- Long-acting granulocyte colony stimulating factors (e.g., Fulphila, Nyvepria, Rolvedon, Udenyca, Ziextenzo): Prime Therapeutics/Gateway PA
- Long-acting insulin (insulin degludec, Lantus, Rezvoglar): Prime Therapeutics/Cover My Meds
- SCIG/IVIG and enzyme replacement therapies (e.g., Lumizyme, Aldurazyme): Prime Therapeutics/Gateway PA
PA submission locations for listed drugs (examples)
The list below gives additional examples of drugs and their PA submission locations. Always verify the submission destination for the specific product and member plan prior to submission.
- Spevigo IV/SQ, Spinraza, Sustol, Susvimo, Syfovre, Synagis, Tecartus, Tecelra, Vyepti, VPRIV — submit to Prime Therapeutics/Gateway PA
- Statin products listed (Altoprev, Atorvaliq, Zypitamag, etc.), Strensiq, substrate reduction therapies (Cerdelga, Opfolda, Zavesca) — submit to Prime Therapeutics/Cover My Meds
- Sunosi, Sucraid, Wakix, weight loss agents listed — submit to Prime Therapeutics/Cover My Meds
PA submission locations for additional specialty agents
Additional oncology, gene therapy, and high-cost specialty agents have specified submission routes; a subset is required to be submitted directly to BCBSKS.
- Oncology and specialty biologics submitted to Prime Therapeutics/Gateway PA include: Keytruda IV/SQ, Kimmtrak, Krystexxa, Kymriah, Tavneos, Talvey, Takhzyro
- Gene and cell therapies or other BCBSKS-direct submissions include: Luxturna, Lyfgenia, Vyjuvek, and other BCBSKS-designated products
- Refer to the individual drug entry for the required submission pathway (Prime Therapeutics Gateway PA, CoverMyMeds, or BCBSKS)
BCBSKS-specific PA submission
BCBSKS-specific submission destination — for certain named products, the PA form must be submitted directly to Blue Cross Blue Shield of Kansas rather than to Prime Therapeutics or CoverMyMeds. Confirm these exceptions for the member's plan before submitting.
- Products requiring submission to BCBSKS: Itvisma, Kebilidi, Luxturna, Lyfgenia, Vyjuvek, and other BCBSKS-designated therapies
Definitions and Submission Pathway Glossary
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