CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Prior Authorization Programs for Members on the Performance Select Drug List

Lists prescription drugs and categories on the Performance Select Drug List and indicates which products within categories are subject to prior authorization programs for Blue Cross Blue Shield - Oklahoma members. Affects providers prescribing or dispensing listed medications to affected members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrior Authorization Programs for Members on the Performance Select Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization or submit an exception request via the phone number on the member ID card or provider portal before dispensing listed Performance Select drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks processed (partial)

20+therapy/drug categories listed

multipledrugs with 2-tier listings

stateapplies to payer level

1contact point

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Coverage Criteria Overview

The extracted sections list drugs and therapeutic categories included in the Blue Cross Blue Shield - Oklahoma Performance Select Drug List. The provided excerpts do not define explicit exclusion criteria; instead, they enumerate products and category mappings that are managed under the payer’s prior authorization programs. Providers should treat the listing as an administrative catalog of drugs that are subject to the plan’s utilization management rather than a statement of clinical exclusions.

Across the presented chunks there are no standalone exclusion statements (for example, no conditions that categorically preclude coverage). The content is primarily a series of drug names, alternative dosage forms, and paired mappings (e.g., “1 =” and “2 =”) used to indicate grouping or relative placement within the Drug List rather than explicit excluded services or therapies.

If a requested drug is not on the Drug List, the member or prescribing provider may request coverage via an exception review. As part of that review, the prescriber and member may need to meet the drug’s prior authorization program criteria before the request can be approved; the review is initiated by calling the phone number on the member’s ID card or by having the provider visit the payer’s website.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Provider Actions & Prior Authorization Requirements

Prior authorization is required for many drugs listed on the Performance Select Drug List. This includes numerous specific branded products and whole therapeutic categories shown in the excerpt. Prescribers should confirm PA requirements before prescribing or dispensing these medications.

Drugs subject to prior authorization: The document enumerates many individual drugs and therapeutic categories (examples below) that are subject to prior authorization as part of the Performance Select Drug List.
Prior authorization subject list: The source lists numerous specific agents (e.g., Accrufer, Reyvow, Emflaza/Agamree, Alhemo, Aimovig, Ajovy, Emgality, Brensocatib, Camzyos, Cibinqo, Corticotropin/Acthar Gel, CFTR modulators such as Kalydeco/Orkambi/Trikafta, GLP-1 agonists including Ozempic/Mounjaro, Hemlibra, Hepatitis C DAAs such as Epclusa/Harvoni/Mavyret, multiple oncology, neurology, hematology, and rare disease therapies) and many grouped category listings (e.g., Biologic Immunomodulators, PCSK9 inhibitors, Pulmonary Arterial Hypertension agents).
Not present in this excerpt: Specific standardized PA clinical criteria (detailed clinical eligibility, trial-of-therapy requirements, exact documentation forms) are not included in the provided excerpts.
Documentation: The document notes that an exception review may require meeting the drug's prior authorization program criteria and that the prescriber or member may need to provide information; contact options include the number on the member ID card or provider portal at bcbsok.com/provider.
Denial triggers: Requests may be denied if the prior authorization or exception review criteria are not met during the review process.
Step/tiers: The source uses paired Tier/Step groupings (denoted as '1 =' and '2 =') across many categories indicating preferred agents (step 1) and alternative/step 2 agents (step 2) which prescribers should follow when applicable.
Paired listings: Many drugs are shown in paired entries (e.g., ATTR amyloidosis: 1 = Attruby/Tegsedi/Vyndaqel; 2 = Vyndamax/Wainua; or PCSK9 inhibitors: 1 = Praluent; 2 = Repatha) illustrating preferred versus alternative products or tiered coverage.
Therapeutic alternatives / step guidance: The listing often pairs a preferred agent with therapeutic alternatives or step options; prescribers should attempt preferred/step 1 agents where required before step 2 alternatives unless clinical justification for exception is documented.

Step Therapy / Tiered Listings

Group	Preferred (1 =)	Alternative (2 =)
{"text":"Biologic Immunomodulators","status":""},{"text":"Nexletol; Abrilada; Actemra subcutaneous; Adalimumab-aacf; Adalimumab-aaty; Adalimumab-adaz; Adalimumab-adbm; Adalimumab-fkjp; Adalimumab-ryvk; Amjevita; Bimzelx; Cimzia; Cosentyx; Cyltezo; Enbrel; Entyvio; Hadlima; adalimumab-bwwd; Hulio; Humira; Humira Starter Kit; Hyrimoz; Idacio; Imuldosa; Kevzara; Kineret","status":""},{"text":"Wainua; Nexlizet; Omvoh; Orencia subcutaneous; Otulfi/ustekinumab-aauz; Pyzchiva; Rinvoq; Selarsdi; Siliq; Simlandi; Simponi; Skyrizi; Sotyktu; Starjemza; Stelara; Steqeyma; Taltz; Tremfya; Tyenne; Ustekinumab-aekn; Velsipity","status":""}

Category	Preferred (1 =)	Alternative (2 =)
{"text":"Multiple Sclerosis","status":""},{"text":"Aubagio; Avonex; Bafiertam; Betaseron; Copaxone; Extavia; Gilenya 0.25 mg; Gilenya 0.50 mg; Kesimpta","status":""},{"text":"Mayzent; Plegridy; Ponvory; Rebif; Tascenso ODT; Tecfidera","status":""}
{"text":"PCSK9 Inhibitors","status":""},{"text":"Praluent","status":""},{"text":"Repatha","status":""}
{"text":"Oxybate (formerly Sodium Oxybate)","status":""},{"text":"Lumryz; Sodium Oxybate","status":""},{"text":"Xyrem; Xywav","status":""}

Oncology / Specialty mapping	Preferred (1 =)	Alternative (2 =)
{"text":"Skyclarys mapping","status":""},{"text":"Skyclarys","status":""},{"text":"Truqap","status":""}
{"text":"Imbruvica mapping","status":""},{"text":"Imbruvica","status":""},{"text":"Tibsovo","status":""}
{"text":"Lenvima mapping","status":""},{"text":"Lenvima","status":""},{"text":"Xospata","status":""}
{"text":"Kisqali mapping","status":""},{"text":"Kisqali","status":""},{"text":"Voranigo","status":""}

Background & Definitions

These policy excerpts are administrative in nature and function as the Performance Select Drug List — a roster of covered and managed prescription products and their alternative formulations or mapped equivalents. The list shows many individual brand and generic agents and uses grouping labels (for example, paired entries and alternate dosage form notes) to indicate how products relate within categories. Changes to the programs and additions to the list may occur over time; the document notes that brand names are third‑party property and the programs are subject to change.

Performance Select Drug List — key facts

DefinitionPerformance Select Drug List: a curated list of prescription drugs and drug categories for which Blue Cross Blue Shield - Oklahoma applies prior authorization programs.

ScopeIncludes specialty drugs and therapeutic categories (e.g., CFTR modulators, ESAs, VMAT2 inhibitors, Urea Cycle Disorder therapies) as shown in the drug-category mappings.

Provider actionDrugs on this list are subject to the payer's prior authorization programs; providers must obtain prior authorization or request an exception per the plan's processes.

Examples includedCFTR modulators (Kalydeco, Orkambi, Symdeko, Trikafta), Erythropoiesis agents (e.g., Aranesp), and multiple other specialty products are listed in the document excerpts.