blue cross blue shield - michigan Prior Auth Criteria Update | OpenPayer
Currentblue cross blue shield - michiganPolicy N/A
Prior Authorization Criteria
Part 1 of a multi-part prior authorization/step therapy formulary document listing drugs subject to PA/ST with short criteria summaries (indications, exclusions, required information, age/prescriber restrictions, coverage duration, other criteria) for Medicare Plus Blue PPO 2025 Plan Year.
Policy Summary
Payerblue cross blue shield - michigan
PolicyPrior Authorization Criteria
Policy CodePolicy N/A
Change TypeFormulary metadata/criteria summary (no material change)
Effective DateDec 1, 2025
Next Review Date
Key ActionObtain prior authorization/step therapy per Formulary ID 25350 Version 21 and submit required documentation (diagnosis, prior trials, labs, mutation testing) as specified for each drug.
Formulary ID, Version, and Effective/Last Updated dates shown (Formulary ID: 25350, Version: 21, Effective Date: 12/01/2025, Last Updated: 12/01/2025).
Part 2 lists many products with their PA requirements; document indicates effective/last updated date 12/01/2025.
This part enumerates product-level other criteria (prior therapy requirements, lab thresholds, combination use constraints) but does not state that clinical policy statements changed from prior versions in this excerpt.
25350 v21Formulary version
MostCoverage durations 1 Year
Multiple
Require prior therapy trials
SeveralReauthorization requires documentation
50+Products listed in this part
Coverage Summary
This document is Part 1 of the Medicare Plus Blue PPO Vitality, Signature and Assure Healthy Value Comprehensive Formulary Prior Authorization / Step Therapy (PA/ST) Program for the 2025 plan year (Formulary ID: 25350, Version: 21, Effective Date: 12/01/2025, Last Updated: 12/01/2025). It lists drugs subject to prior authorization or step therapy and provides per-product PA/ST entry summaries (indications, exclusions, required information, prescriber/age restrictions, other criteria) to guide providers. Coverage durations are specified per product; the majority of listed products show a coverage duration of 1 YEAR, with some exceptions noted in individual entries. Entries in this part are product-specific and repeat the formulary metadata across items; each drug entry indicates whether PA or ST applies and any product-level PA/ST requirements (for example, required prior trials, lab thresholds, combination restrictions).
Formulary metadata & summary
Formulary IDFormulary ID: 25350
VersionVersion: 21
Effective DateEffective Date: 12/01/2025
Last UpdatedLast Updated: 12/01/2025
Typical coverage durationMost products: 1 YEAR (product-specific exceptions noted)
Number of products listed in this part>100 (many entries; Part lists ~60–120 per part; stats show 40+ to 100+ entries)
Common provider actions summaryObtain PA/ST per Formulary ID 25350; document required prior trials, diagnostic tests, and lab values (e.g., mutation testing, T25FW, eosinophil counts); supply reauthorization evidence of positive clinical response when required
Initial Therapy Criteria (per product)
Initial Therapy Criteria (per product)
Initial authorization is required when ALL specified product-level prerequisites are met. Each product entry below lists the typical coverage conditions (diagnosis, required prior trials, prescriber restrictions, and coverage duration) as extracted from the source. Where combination use or step trials are required, that requirement is shown explicitly.
ALL of the following
Kevzara (sarilumab): Coverage requires documented diagnosis matching FDA-approved indication (e.g., rheumatoid arthritis). Prior biologic DMARD response/intolerance or contraindication documentation required per product labeling. Prescriber restrictions: typically required to be prescribed by or in consultation with a rheumatologist. Coverage duration: 1 year.
ALL of the following
Kineret (anakinra): Coverage requires diagnosis consistent with indicated inflammatory condition (e.g., rheumatoid arthritis or NOMID per labeling). Documentation of prior appropriate therapies or rationale for use required. Prescriber restrictions: specialist (e.g., rheumatology) involvement recommended. Coverage duration: 1 year.
ALL of the following
Continuation / Reauthorization Criteria
Reauthorization rules and product-specific reauthorization notes
Reauthorization and cross‑product reauthorization rules: general reauthorization expectations and specific product notes that require documentation of positive clinical response or disallow certain combinations at renewal.
General cross-product reauthorization rules: REAUTHORIZATION REQUIRES DOCUMENTATION OF POSITIVE CLINICAL RESPONSE TO THERAPY for many biologic and specialty products; coverage durations specified per product (commonly 1 YEAR).
Appears as common reauthorization requirement across multiple product entries (see individual products for exact wording).
Enbrel / other TNF inhibitors - reauthorization: For all indications reauthorization requires documentation of positive clinical response to therapy; exclusion: cannot be used in combination with another biologic/targeted DMARD indicated for same condition; coverage duration: 1 YEAR.
Combination exclusions and product-specific combination prohibitions
Exclusions and prohibited combination rules (general cross‑product exclusions and product‑specific combination prohibitions).
General combination exclusion: CANNOT BE USED IN COMBINATION WITH ANOTHER BIOLOGIC OR TARGETED DMARD INDICATED FOR THE SAME CONDITION — statement appears across many biologic product entries and is enforced as an exclusion for coverage when present.
Listed as an exclusion item in multiple product entries.
Products explicitly prohibiting combination with other biologics/targeted DMARDs or potent immunosuppressants: Examples include: Cosentyx (cannot be used in combination with another biologic or targeted DMARD indicated for the same condition); Dupixent (cannot be used in combination with another biologic/targeted DMARD for same condition); Enbrel, Xolair, Nucala, Fasenra, Skyrizi, Wezlana/Yesintek, Otezla and many JAK/biologic entries (e.g., Rinvoq, Xeljanz, Orencia) include combination prohibitions or 'cannot be used with potent immunosuppressant' language; some products (e.g., Joenja) disallow combination with immunosuppressive medications for specific indications.
Product-specific exclusions should be checked per drug entry.
Applicable Codes / Formulary Identifiers
Formulary identifiers / metadatamixed
Formulary ID: 25350
Formulary identifier repeated for entries in this part
Version: 21
Formulary version for entries in this part
Effective Date: 12/01/2025
Effective date shown on document
Last Updated: 12/01/2025
Last updated date shown on document
Formulary / product list codes referenced in this partmixed
Formulary ID 25350
Master formulary identifier for entries in this document (Version 21)
Formulary ID: 25350
Applies to all products listed in this part; Version 21 effective 12/01/2025
Provider Actions & Billing Rules
Prior Authorization
Prior Authorization Required
Obtain prior authorization for listed PA drugs. Prior authorization is required per product and product-specific criteria must be met before coverage is provided. Reference: Formulary ID 25350. To request PA or ST, contact the Blue Cross pharmacy help desk using the customer service number on the back of the member's ID card.
Prior authorization required per product — follow product-specific PA criteria.
Reauthorization requires evidence of clinical response and continued medical necessity.
Product-specific prior authorization required (see individual drug criteria in formulary).
Documentation for Xilbrysq (Zilbrysq) and other agents must meet the listed product criteria.
Documentation Required
Documentation Required for PA and Reauthorization
Clinical Evidence / Thresholds
Clinical numeric thresholds (selected)
Dupixent - EA eosinophil threshold>= 150 cells per microliter
Dupixent - COPD add-on eosinophil threshold>= 300 cells per microliter
Fasenra initiation eosinophil threshold>= 150 cells per microliter
Nucala - EA eosinophil threshold>= 150 cells per microliter at initiation
Nucala - COPD eosinophil thresholdscurrent >=150 cells/µL OR >=300 cells/µL within past 12 months
Nucala - HES eosinophil threshold>= 1000 cells per microliter at initiation
Dalfampridine ER - walk test
Background
This document is part of the Medicare Plus Blue PPO Vitality, Signature and Assure Healthy Value Comprehensive Formulary Prior Authorization / Step Therapy Program for plan year 2025 and summarizes PA/ST product lists and brief criteria to guide providers on required trials and documentation. It clarifies that drugs subject to PA/ST are identified in the formulary and that PA/ST must be obtained prior to coverage, with PA criteria listed first and ST criteria following. The clinical criteria are based on current medical information and Pharmacy & Therapeutics Committee recommendations.
Definitions used in this part include:
- PA (Prior authorization): clinical and/or administrative criteria must be met before coverage is provided.
- ST (Step therapy): requires previous treatment with one or more formulary drugs prior to coverage.
- Reauthorization: renewal of prior authorization; often requires documentation of a positive clinical response to therapy as specified per product.
- Formulary ID 25350: identifier for this payer's formulary/prior authorization criteria set (Version 21, effective 12/01/2025).
- DMARD (disease‑modifying antirheumatic drug): examples cited include methotrexate, leflunomide, sulfasalazine and are referenced as required prior therapies for some rheumatologic biologics.
- Coverage Duration: the time period authorization is provided (commonly 1 YEAR for most products in this part; other durations appear for specific drugs).
Revision History
12/01/2025POLICY UPDATE CHANGESLatest
Formulary ID: 25350, Version: 21 published with Effective Date 12/01/2025 and Last Updated 12/01/2025; metadata repeated across entries in this part.
12/01/2025POLICY UPDATE CHANGESLatest
Part lists product-level prior authorization criteria (coverage durations, prior therapy requirements, lab/diagnostic thresholds, combination use constraints) for many drugs under Formulary ID 25350 Version 21.
12/01/2025POLICY UPDATE CHANGES
Policy Summary
Payerblue cross blue shield - michigan
PolicyPrior Authorization Criteria
Policy CodePolicy N/A
Change TypeFormulary metadata/criteria summary (no material change)
Effective DateDec 1, 2025
Next Review Date
Key ActionObtain prior authorization/step therapy per Formulary ID 25350 Version 21 and submit required documentation (diagnosis, prior trials, labs, mutation testing) as specified for each drug.
Kisqali (ribociclib): Coverage for HR-positive, HER2-negative advanced or metastatic breast cancer requires documentation of hormone receptor status and combination use with an aromatase inhibitor or fulvestrant as indicated. Trial of appropriate endocrine therapy (letrozole or anastrozole) required where specified. Coverage duration: 1 year.
ALL of the following
Mifepristone 300 mg: Coverage limited to FDA-approved indications and settings; documentation of diagnosis and compliance with required protocols and prescriber qualifications required. Coverage duration: as medically necessary per policy.
ALL of the following
Koselugo (selumetinib): Coverage for neurofibromatosis type 1 (NF1) plexiform neurofibromas requires documentation of symptomatic, inoperable plexiform neurofibroma and specialist (e.g., oncology/neurology) prescribing. Coverage duration: 1 year.
ALL of the following
Krazati (adagrasib): Coverage for KRAS G12C–mutated cancers requires documentation of tumor mutation testing confirming KRAS G12C. Prior lines of therapy per indication and specialist (oncology) prescribing required. Coverage duration: 1 year.
ALL of the following
Lazcluze (amivantamab combination requirement): Coverage requires combination use as specified by indication (e.g., in combination with other agents per FDA labeling). Documentation of mutation status or other biomarker testing and specialist prescribing required. Coverage duration: 1 year.
ALL of the following
Lenvima (lenvatinib): Coverage requires diagnosis consistent with approved indications (e.g., thyroid cancer, RCC in combination, hepatocellular carcinoma). Prior therapy trials (e.g., sunitinib or sorafenib) required for some indications as specified. Prescriber: oncology or appropriate specialist. Coverage duration: 1 year.
ALL of the following
Leuprolide acetate / Lupron depot: Coverage requires diagnosis consistent with approved indications (e.g., prostate cancer, endometriosis). Documentation of indication, dosing interval, and prescriber specialty required. Coverage duration: 1 year.
ALL of the following
Libervant: Coverage requires diagnosis of focal seizures appropriate for product use and documentation of prior anticonvulsant therapy trials if applicable. Prescriber: neurology recommended. Coverage duration: 1 year.
ALL of the following
Libtayo (cemiplimab): Coverage requires diagnosis consistent with approved oncology indications (e.g., cutaneous squamous cell carcinoma, certain NSCLC). Documentation of prior therapies per indication and specialist prescribing required. Coverage duration: 1 year.
ALL of the following
Lidocaine PTCH 5% / Lidocaine/prilocaine cream: Coverage requires diagnosis and indication (e.g., localized neuropathic pain, topical anesthetic use). Quantity limits and application instructions may apply. Coverage duration: 1 year.
ALL of the following
Livtencity (maribavir): Coverage for CMV infection in transplant recipients requires documented refractory/resistant CMV infection or indication per labeling and specialist (infectious disease/transplant) prescribing. Coverage duration: 1 year.
ALL of the following
Lonsurf (trifluridine/tipiracil): Coverage for metastatic colorectal cancer requires prior lines of therapy as specified in labeling and oncology prescribing. Coverage duration: 1 year.
ALL of the following
Lorbrena (lorlatinib): Coverage for ALK-positive metastatic NSCLC requires documentation of ALK positivity and prior ALK inhibitor therapy per labeling; specialist prescribing required. Coverage duration: 1 year.
ALL of the following
Lumakras (sotorasib): Coverage requires documented KRAS G12C mutation and prior therapy per indication; oncology prescribing required. Coverage duration: 1 year.
ALL of the following
Lybalvi (olanzapine/samidorphan): Coverage for schizophrenia or bipolar disorder requires diagnosis documentation and prior antipsychotic therapy history where applicable. Prescriber: psychiatry recommended. Coverage duration: 1 year.
ALL of the following
Lynparza (olaparib): Coverage for BRCA-mutated cancers requires documented germline or somatic BRCA mutation testing and indication-specific prior therapy documentation. Specialist prescribing required. Coverage duration: 1 year.
Magenza (margetuximab): Coverage for metastatic HER2-positive breast cancer requires documentation of HER2-positive status and prior anti-HER2 therapy per labeling. Prescriber: oncology required. Coverage duration: 1 year.
ALL of the following
Mekinist (trametinib) — tablets and oral liquid: Coverage requires diagnosis consistent with approved indications (e.g., BRAF-mutated melanoma, NSCLC). For pediatric/young patients where liquid formulation is needed, documentation of inability to use tablets required. Specialist prescribing required. Coverage duration: 1 year.
ALL of the following
Mektovi (binimetinib): Coverage requires diagnosis and mutation status per labeling (e.g., BRAF V600-mutant melanoma) and specialist prescribing. Coverage duration: 1 year.
ALL of the following
Memantine products: Prior authorization required; coverage limited to FDA-approved indications (e.g., moderate to severe Alzheimer disease). Documentation of diagnosis and prior therapies may be requested. Coverage duration: 1 year.
ALL of the following
Meprobamate: Coverage requires diagnosis and justification for use; prior alternatives may be required. Coverage duration: 1 year.
ALL of the following
Miglustat / Yargesa / Opfolda (miglustat-related products): Coverage requires diagnosis consistent with approved indications (e.g., certain lysosomal storage disorders); specialist prescribing and diagnostic testing required. Coverage duration: 1 year.
ALL of the following
Modeyso: Coverage requires diagnosis per indication and prescriber documentation. Coverage duration: 1 year.
ALL of the following
Monjuvi: Coverage requires diagnosis of relapsed/refractory diffuse large B-cell lymphoma per labeling and specialist oncology prescribing; prior therapies per indication may be required. Coverage duration: 1 year.
ALL of the following
Motpoly XR (for seizures): Coverage requires diagnosis of epilepsy and documentation of prior anticonvulsant therapy trials as applicable; neurology prescribing recommended. Coverage duration: 1 year.
ALL of the following
Movantik (naldemedine): Coverage for opioid-induced constipation requires documentation of chronic opioid use and failure of laxative therapy; prescriber documentation required. Coverage duration: 1 year.
ALL of the following
Myalept: Coverage requires diagnosis of leptin deficiency as indicated and endocrinology prescribing; diagnostic confirmation required. Coverage duration: 1 year.
ALL of the following
Armodafinil / Modafinil: Coverage requires diagnosis (e.g., narcolepsy, shift work sleep disorder) and documentation of prior treatments or diagnostic testing; prescriber documentation required. Coverage duration: 1 year.
ALL of the following
Fentanyl citrate oral transmucosal: Coverage requires documentation of cancer-related breakthrough pain and prior opioid therapy; quantity limits and safe-prescribing documentation required. Coverage duration: 1 year.
ALL of the following
Nayzilam: Coverage requires diagnosis of seizure clusters and prior therapy documentation; neurologist prescribing recommended. Coverage duration: 1 year.
ALL of the following
Nerlynx (neratinib): Coverage requires diagnosis of HER2-positive early breast cancer as indicated and prior trastuzumab treatment per labeling; specialist prescribing required. Coverage duration: 1 year.
ALL of the following
Neulasta / Neulasta Onpro: Coverage requires indication documentation (e.g., chemotherapy-induced neutropenia prophylaxis). Prescriber required; coverage duration usually 1 year or per chemotherapy cycle.
ALL of the following
Sorafenib: Coverage requires indication documentation and prior therapy where applicable; specialist prescribing required. Coverage duration: 1 year.
ALL of the following
Nexletol / Nexlizet: Coverage requires diagnosis of primary hypercholesterolemia or mixed dyslipidemia with documentation of lipid levels and prior statin therapy/intolerance. Prescriber documentation required. Coverage duration: 1 year.
ALL of the following
Ninlaro (ixazomib): Coverage requires indication documentation for multiple myeloma and prior therapy as applicable; oncology prescribing required. Coverage duration: 1 year.
ALL of the following
Droxidopa: Coverage for neurogenic orthostatic hypotension requires diagnosis, prior medication history, and specialist prescribing. Coverage duration: 1 year.
ALL of the following
Nubeqa: Coverage requires diagnosis of nonmetastatic castration-resistant prostate cancer per labeling and prior androgen-deprivation therapy documentation; oncology/urology prescribing required. Coverage duration: 1 year.
ALL of the following
Nucala (mepolizumab): Coverage requires diagnosis of severe eosinophilic asthma with eosinophil count per labeling and prior controller therapy trial documentation; specialist prescribing recommended. Coverage duration: 1 year.
ALL of the following
Nuedexta (dextromethorphan/quinidine): Coverage requires diagnosis of pseudobulbar affect or other approved indication and documentation of prior therapy or rationale. Prescriber documentation required. Coverage duration: 1 year.
ALL of the following
Nuplazid (pimavanserin): Coverage requires diagnosis of hallucinations and delusions associated with Parkinson's disease psychosis per labeling; specialist prescribing required. Coverage duration: 1 year.
ALL of the following
Nurtec (rimegepant): Coverage for acute and preventive migraine requires diagnosis documentation and prior therapy trials per plan policy; prescriber documentation required. Coverage duration: 1 year.
Orkambi / Orserdu / Otezla / Oxbryta / Padcev / Panretin / Pemazyre / Phenobarbital products / Piqray / Polivy / Pomalyst / Posaconazole DR / Praluent (pending) / Pretomanid / Prevymis / Prolia / Eltrombopag (Promacta) / PAH agents / Qinlock / Quinine / Qulipta / Raldesy / Ravicti / Recorlev / Repatha / Retevmo / Lenalidomide / Revuforj / Rezlidhia / Rezurock / Rinvoq (oral and liquid) / Rivfloza / Romvimza / Rozlytrek / Rubraca / Rybrevant / Rydapt / Rylaze / Tolvaptan / Sapropterin / Sarclisa / Savella / Scemblix / Secuado / Sohonos / Lanreotide (Somatuline) / Somavert / Spritam / Sprycel / Wezlana: For these products, coverage requires documentation of the FDA-approved diagnosis, relevant biomarker or diagnostic testing where applicable, prior therapy trials or contraindications as specified in the formulary notes, and specialist prescribing when indicated. Many entries specify a 1-year coverage duration; individual product entries may include further required trials (e.g., trial of letrozole/anastrozole prior to some breast cancer agents) or combination therapy requirements.
These biologics explicitly state that reauthorization requires documentation of positive clinical response to therapy; many also include combination exclusions (cannot be used with another biologic/targeted DMARD for same condition).
Product‑specific reauth language captured from each entry.
Dalfampridine ER - reauthorization: Reauthorization requires documentation of stability or improvement on the Timed 25‑foot Walk (T25FW) test.T25FW stability or improvement
Product‑specific reauth metric.
Orencia / Rinvoq / Xeljanz - reauthorization and combination exclusions: Reauthorization requires documentation of positive clinical response and specifically that the patient is not receiving the agent in combination with other immunosuppressives or biologic/targeted DMARDs (e.g., Orencia cannot be combined with JAK inhibitors or biologic DMARDs; Rinvoq cannot be used with a potent immunosuppressant or another biologic/targeted DMARD).
Cross‑product prohibition and reauth documented.
Wezlana / Yesintek - reauthorization: For all indications reauthorization requires documentation of positive clinical response to therapy; exclusion: cannot be used in combination with another biologic/targeted DMARD for same condition; coverage duration: 1 YEAR.
Example of product‑level reauth note.
Orencia / Xeljanz / Rinvoq family exclusions: Orencia: CANNOT BE USED IN COMBINATION WITH OTHER IMMUNOSUPPRESSIVES (e.g., JAK inhibitors, biologic DMARDs). Xeljanz and Rinvoq: cannot be used in combination with a potent immunosuppressant (e.g., azathioprine, cyclosporine) or another biologic/targeted DMARD for same condition; reauthorization requires patient is not receiving prohibited combinations.
Explicit combination prohibitions with examples provided in product entries.
Joenja (leniolisib) - APDS combination exclusion: For APDS indication Joenja CANNOT BE USED IN COMBINATION WITH AN IMMUNOSUPPRESSIVE MEDICATION; coverage requires documented PI3Kδ mutation and associated diagnostic criteria; coverage duration: 1 YEAR.
Product‑specific combination exclusion.
Skyrizi / Dupixent / Nucala - biologic combination prohibitions: Skyrizi and other IL‑targeting biologics include 'cannot be used in combination with another biologic or targeted DMARD indicated for the same condition' as an exclusion; Dupixent and Nucala similarly include combination prohibitions in their entries.
Reinforces cross‑product exclusion language.
Submit required documentation and diagnostic results to support PA requests and reauthorizations. Provide copies of relevant lab reports, objective test results, prior therapy trials, and specialty testing when indicated.
Provide lab confirmation when required (e.g., eosinophil counts, disease‑specific labs).
Weight documentation required for Wezlana/Yesintek 90 mg/mL dosing verification.
Bone mineral density (BMD) report required for Tymlos reauthorization or baseline assessment.
Document required prior trials and diagnostics (e.g., T25FW for mobility, Bronchitol tolerance where applicable).
Reauthorization documentation must include evidence of response and continued clinical benefit.
Step Therapy
Step Therapy / Prior Trial Requirements
Step therapy expectations: trials of specified agents or generic therapies are required before coverage of some non‑formulary or brand agents. Provide evidence of prior therapy trials and dates.
Trials of generics before coverage — e.g., trial of generic oral donepezil required prior to coverage of Adlarity.
Complete required prior trials of 2 generic anticonvulsants for Aptiom coverage.
Trials of specified agents (e.g., letrozole or anastrozole before everolimus combinations; sunitinib or sorafenib for certain RCC indications).
Step therapy / trial requirements must be documented with dates, doses, and reason for failure or intolerance.
Denial Risk
Common Denial Risks & Exclusions
Common denial risks and exclusions to watch for — missing required tests, excluded diagnoses, prohibited combinations, and incorrect benefit channel (Part B vs Part D). Address these proactively in the submission to avoid denials.
Denial risk for missing required tests or documentation (labs, objective measures, prior trial evidence).
Excluded conditions — e.g., dalfampridine use is contraindicated for members who are non-ambulatory or permanently wheelchair‑bound.
Combination therapy exclusions and concomitant therapy restrictions: coverage may require or prohibit combination use (provide documentation if combination is required).
Part B vs Part D coverage issues — certain drugs or supplies may be reviewed for Part B coverage instead of Part D; verify benefit channel.
Billing Rule
Billing Rules & Supplies Linkage
Billing rules and supply linkage guidance — follow payer rules for benefit determination and supplies linkage (e.g., insulin supplies may link to an insulin claim).
Part B vs Part D guidance: determine whether the drug or related supply should be billed to Part B or Part D to avoid inappropriate denials.
Insulin supply linkage: supplies coverage may be linked to an insulin claim within the prior 180 days; document associated insulin therapy to support supply coverage.
Follow payer billing rules for administered drugs and durable medical equipment as applicable.
Baseline timed 25-foot walk (T25FW) required; reauth requires stability or improvement on T25FW
Prolastin-c / Zemaira - FEV1FEV1 < 80% predicted
Repatha - LDL thresholds (ASCVD)LDL >= 70 mg/dL with ASCVD
Repatha - LDL thresholds (no ASCVD)LDL > 100 mg/dL without ASCVD
GLP-1 agonists - diabetes diagnostic thresholdsA1c >= 6.5% OR FPG >= 126 mg/dL OR 2-hour PG >= 200 mg/dL (OGTT)
No formal clinical trial evidence section is provided in this part of the formulary. The authorization criteria are described as being based on current medical information and the recommendations of the Blues' Pharmacy & Therapeutics Committee; clinical criteria and product-specific requirements (prior trials, lab values, combinations) are used to determine PA/ST decisions per the General Program Statement. The brief's evidence field is empty, consistent with the absence of an independent clinical evidence section in this excerpt.
Latest
This part enumerates specific other criteria (prior therapy requirements, lab thresholds, age/prescriber restrictions) but does not indicate material clinical policy statement changes in this excerpt.