CurrentBlue Cross Blue Shield - LouisianaPolicy N/A

Prescription Drugs Requiring Prior Authorization

List and program requirements for prescription drugs that require prior authorization through the payer's pharmacy benefit manager (Express Scripts). Applies to members and prescribing physicians using the payer's prescription drug benefits.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyPrescription Drugs Requiring Prior Authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPhysicians must call Express Scripts (1-800-842-2015) to obtain prior authorization for listed prescription drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manydrug entries listed

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>90/moopioid ER quantity note

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ESIPA processor

Coverage Criteria Overview

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization: 1-800-842-2015. Failure to obtain prior authorization from Express Scripts may result in denial of coverage for drugs listed on the prior authorization list.

Prior authorization is required for the prescription drugs enumerated in this document; providers must submit PA requests to Express Scripts, Inc. (ESI).
Prior authorization requests are processed by ESI — physicians should call 1-800-842-2015 to obtain authorizations.
Inclusion of a drug on this list does not guarantee coverage; benefits may vary by group/plan and the Schedule of Benefits should be consulted.
Drugs listed (selected examples across the document) that require prior authorization include: DOJOLVI (triheptanoin), DOPTELET (avatrombopag), DOVATO (dolutegravir‑lamivudine), HYSINGLA ER, ILUMYA (tildrakizumab‑asmn), INFLECTRA (infliximab‑dyyb), NUCALA (mepolizumab), OXYCODONE ER / OXYCONTIN (quantities >90 per month may trigger PA), OZEMPIC (semaglutide), SOLIRIS (eculizumab), SPINRAZA (nusinersen), STELARA (ustekinumab), ZOLGENSMA (onasemnogene abeparvovec‑xioi), YESCARTA (axicabtagene ciloleucel), and many others listed in the formulary segments.
Quantities greater than 90 per month for certain extended‑release opioid products (e.g., oxycodone ER / OXYCONTIN) may require prior authorization.
Generic versions of some drugs may be excluded from the Prior Authorization Program (e.g., noted generics not included).
Prior authorization must be obtained before coverage under the prescription drug benefit; claims submitted without required PA are subject to denial or retrospective review.

Documentation Required

Documentation Requirement

Providers must submit prior authorization requests and supporting documentation for drugs appearing on the 'Prescription Drugs Requiring Prior Authorization' list. Requests are subject to review and may be denied if PA is not obtained.

Prior authorization documentation must demonstrate medical necessity consistent with plan coverage and any clinical criteria applied by ESI.
If the requested quantity exceeds program limits (for example, >90/day or >90 per month where noted), include justification for the higher quantity.
Failure to provide required documentation may result in denial of the PA request.

Prior Authorization

Drugs Requiring Prior Authorization (examples)

Selected drug examples from the PA list (consolidated across the formulary segments). This is not exhaustive; consult the full formulary list for all covered entries.

DOJOLVI (triheptanoin) — Nutrient - Lipids
DOPTELET (avatrombopag) — Thrombopoietic Agent
DOVATO (dolutegravir‑lamivudine) — HIV/AIDS
HYSINGLA ER — Analgesics - Opioid
ILUMYA (tildrakizumab‑asmn) — Monoclonal Antibody
INFLECTRA (infliximab‑dyyb) / INFLIXIMAB — Monoclonal Antibody
NUCALA (mepolizumab) — Monoclonal Antibody
OXYCODONE ER / OXYCONTIN — Analgesics - Opioid (quantities >90 per month may require PA)
OZEMPIC (semaglutide) — Incretin Mimetic Agent
SOLIRIS (eculizumab) — Paroxysmal Nocturnal Hemoglobinuria
SPINRAZA (nusinersen) — Spinal Muscular Atrophy
STELARA / YESINTEK (ustekinumab and biosimilars) — Monoclonal Antibody
ZOLGENSMA (onasemnogene abeparvovec‑xioi) — Spinal Muscular Atrophy (gene therapy)
YESCARTA (axicabtagene ciloleucel) — Oncology (CAR‑T therapy)

Definitions

inv-30: Prior authorization definition — Prior authorization: a requirement to request and receive approval from the pharmacy benefit manager before a drug is covered under the member's prescription benefit.

DefinitionPrior authorization: a requirement to request and receive approval from the pharmacy benefit manager before a drug is covered under the member's prescription drug benefits.

ProcessorPrior authorization requests are processed by Express Scripts, Inc. (ESI)

How to requestPhysicians must call ESI to obtain an authorization (1-800-842-2015).

inv-31: Monoclonal Antibody definition — Monoclonal Antibody = biologic therapeutic agents listed by generic/brand name.

DefinitionMonoclonal Antibody: biologic therapeutic agents identified on the list by generic and brand name (e.g., INFLECTRA — infliximab-dyyb; NUCALA — mepolizumab).

ExamplesINFLECTRA (infliximab-dyyb); NUCALA (mepolizumab); SPEVIGO (spesolimab-sbzo)

ClassificationListed drug entries include the medication name and 'Drug Classification = Monoclonal Antibody' where applicable.

inv-32: Prior Authorization list — Definition/label for the PA list.

Label'Prescription Drugs Requiring Prior Authorization' — roster of drugs that require prior authorization under the prescription drug benefit.

ContentsIncludes brand and generic names plus drug classification to indicate products subject to prior authorization.

NotesInclusion on the list does not guarantee coverage; benefits may vary by group and individual plans.

inv-33: Prior authorization (duplicate) — Administrative requirement for coverage approval for the listed prescription drugs.

DefinitionPrior authorization: administrative requirement to obtain approval before coverage is granted for the prescription drugs listed in this document.

EnforcementClaims for listed drugs submitted without prior authorization may be denied.

Provider actionProviders must submit prior authorization requests for drugs appearing on the PA list.

OpenPayer

Prescription Drugs Requiring Prior Authorization

Coverage Criteria Overview

Documented Drug List / Coding Extracts

Provider Actions and Prior Authorization Requirements

Background and Purpose

Definitions

Quantity Limit Notes