CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Prior Authorization Programs for Members on the Performance Biosimilar Drug List

This document lists prescription drug categories and products subject to prior authorization under Blue Cross Blue Shield - Oklahoma's Performance Biosimilar Drug List; it applies to members and providers requesting coverage for listed non-specialty and specialty drugs.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrior Authorization Programs for Members on the Performance Biosimilar Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is required for listed prescription drugs; initiate review by calling the number on the member ID card or visiting bcbsok.com/provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+drug categories and entries listed in this part of the document

includes specialty and non-specialtytypes of prior authorization designations shown

contactmember/provider phone or website for prior authorization initiation

examples onlylisted drugs are examples and subject to change

Prior Authorization Coverage Criteria

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Coverage stance for listed drugs

Coverage for the drugs listed in this section is managed through prior authorization. The document distinguishes Non‑Specialty Prior Authorization and Specialty Prior Authorization designations; specific clinical criteria and detailed submission requirements are not included in this listing.

Prior authorization is required for prescription drugs listed on the Performance Biosimilar Drug List.

The list uses designations such as Non‑Specialty Prior Authorization and Specialty Prior Authorization to indicate the type/level of prior authorization required for specific products.

This portion of the document presents the managed drug categories and example products but does not provide individual clinical criteria or submission instructions; providers should initiate authorization requests via the contact methods shown elsewhere in the policy.

Listed drug categories and examples

The following are examples of drug categories and representative products that are included in the prior authorization program(s). These entries are illustrative; the programs and included products may change.

Examples

Multiple Sclerosis: examples include Aubagio, Avonex, Bafiertam, Betaseron, Copaxone, Extavia, Gilenya 0.25 mg, Mavenclad, Mayzent, Plegridy, Ponvory, Rebif, Tascenso ODT
Lupus (formerly Benlysta): examples include Benlysta, Lupkynis
Polycystic Kidney: examples include Jynarque, tolvaptan

Additional neurologic and rare disease categories

Neurotrophic keratitis: Oxervate
Niemann‑Pick disease agents: Aqneursa
Oxybate products: Lumryz, Xyrem/Xywav

Biologics and immunomodulators

Biologic immunomodulators / arthritis/psoriasis examples: Abrilada, Actemra (subcutaneous), Amjevita, Cimzia, Otulfi, Rinvoq
Somatostatins and related agents: Mycapssa, Somavert

Oncology and specialty therapies

Examples include Skyclarys, Nerlynx, Nexavar, Sohonos, Spevigo, Strensiq
Substrate reduction and related therapies: Cerdelga, Opfolda, Zavescal

Other categories noted in the list

GLP‑1 agonists: Bydureon BCise, Byetta, exenatide, liraglutide, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza
CGRP agents: Aimovig, Ajovy, Nurtec ODT, Qulipta
Cannabidiol: Epidiolex

Entries above are representative examples drawn from the Performance Biosimilar Drug List; refer to the full list for other categories and products and for official prior authorization designations.

Coding and Code References

No billing or procedure codes provided in this partmixed

No codes listed

Self-administered oncology and other listed medicationsmixed

No codes listed

Document structure — multi-column product mapping

Presentation formatDrugs are shown in multi-column category rows where each category row maps to multiple numbered/product columns (e.g., 1 = product A, 2 = product B).

Numbered/product columnsIndividual products within a category are listed using numbered columns (1, 2, etc.) that map to specific brand or biosimilar entries in the row.

Category rowsEach therapeutic or indication category is presented as a distinct row that groups related prescription products together for prior authorization reference.

Purpose of layoutThe multi-column mapping clarifies which specific products within a category are subject to prior authorization designation (non-specialty or specialty).

Provider Actions and Authorization Process

Prior Authorization

Prior authorization required; Non‑Specialty and Specialty designations

Prior authorization is required for the prescription drugs listed on the Performance Biosimilar Drug List. The list distinguishes Non‑Specialty Prior Authorization and Specialty Prior Authorization designations for specific products.

Prior Authorization

How to initiate prior authorization

To start the prior authorization review, call the number on the member's ID card or ask the prescribing clinician to initiate the request via bcbsok.com/provider.

Note

Contact for questions

For questions about prior authorization or the Performance Biosimilar Drug List, call the phone number listed on the member's ID card.

Definitions and Program Notes

Prior authorization designations

Non-Specialty Prior AuthorizationLabel used to indicate prescription drugs within a category that require standard (non-specialty) prior authorization.

Specialty Prior AuthorizationLabel used to indicate prescription drugs that require specialty-level prior authorization (designated as Specialty Prior Authorization in the list).

Designation shown per productThe list applies the Non‑Specialty or Specialty designation to specific products within the category rows to indicate the required level of prior authorization.

Performance Biosimilar Drug List prior authorization programs

Listed drugs are examplesThe document states the listed drug categories and specific medications are only examples and programs are subject to change.

Programs subject to changeThese prior authorization programs may change from time to time and additional drugs may be added to the categories listed.

Third-party brand name disclaimerThird-party brand names are the property of their respective owners.

How to start prior authorizationTo start the review process, call the number on your Member ID card or ask your doctor to visit bcbsok.com/provider.