CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Prior Authorization/Step Therapy Program (partial listing, part 1 of 2)

Lists multiple prior-authorization and specialty prior-authorization program categories and their target drugs and program intents for Blue Cross Blue Shield - Oklahoma; this is part 1 of 2 and contains enumerated therapeutic classes, target drugs, and high-level program intents (no detailed clinical criteria in this part).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrior Authorization/Step Therapy Program (partial listing, part 1 of 2)

Policy CodePolicy N/A

Change TypeClarified / Added (informational)

Effective Date

Next Review Date

Key ActionPrescribers must request prior authorization per the program before coverage is allowed.

POLICY UPDATE CHANGES

Enumerates numerous prior authorization and specialty prior authorization program categories with their target drugs and high-level program intents.

Enumerates multiple specialty prior authorization and step therapy program categories and their target drugs/program intents (e.g., Neurotrophic Keratitis: Oxervate; Oxybate: Lumryz, Sodium Oxybate, Xyrem, Xywav; many others).

Notes that a manufacturer discontinued a product in early 2024.

100+Listed Target Drugs (partial doc)

MultipleProgram Categories Listed

~100Entries in Part 2

Summary of this change bulletin (partial prior-auth / step therapy listing)

This bulletin is Part 1 of 2 and provides a partial listing of the payer's Prior Authorization/Step Therapy Program. It enumerates multiple program categories and the target drug names included in each category and supplies a one-sentence program intent for each entry.

This part is partial and informational only: it contains program categories, target drug names, and brief program intents but does NOT include clinical coverage criteria, decision trees, or threshold requirements. Part 2 contains the middle section of the alphabetized list and additional entries.

Use this document as an overview of the program categories and target agents; clinical coverage rules, specific criteria, and any numeric thresholds are located in the plan's full policy documents and the other part(s) of the listing.

Document-level stats

Listed Target Drugs (partial)100+

Program Categories ListedMultiple

Listed drug/program entries in Part 2~100

Manufacturer discontinuation noted1

Phone number provided for verification1

Enumerated program categories and target drugs (partial list)

Render a concise lead for this section: it lists the program categories with their target drugs and one-sentence program intents as presented in Part 1 of 2. No clinical coverage criteria or numeric thresholds are provided in this part; the list is informational.

Program Category	Target drugs / Program intent (one-line)
CGRP (Calcitonin Gene-Related Peptide)
Target drugs: Qulipta, Ubrelvy, Zavzpret — Helps select patients per product labeling/guidelines and dosing
GLP-1 (glucagon-like peptide-1) Agonists
Target drugs: Bydureon BCise, Byetta, Exenatide, Liraglutide, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza — Helps select patients per product labeling/guidelines and encourages trial of antidiabetic agent
Insulin Pumps
Target devices: iLet Bionic Pancreas, Omnipod (Classic, DASH, 5 G6, 5 G7) kits/pods, twiist — Helps select patients per product labeling/guidelines and dosing
Hepatitis C Direct Acting Antivirals
Target drugs: Epclusa, Harvoni, Ledipasvir/Sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier — Select patients per labeling/guidelines; preferred agent by genotype typically required before non-preferred
Neurotrophic Keratitis
Target drug: Oxervate — Helps select patients per product labeling/guidelines and dosing
Oxybate (formerly Sodium Oxybate)
Target drugs: Lumryz, Sodium Oxybate, Xyrem, Xywav — Helps select patients per product labeling/guidelines and dosing
Many other specialty categories (examples in list)
Includes categories such as Biologic Immunomodulators, CFTR, Hemophilia factors, PCSK9 inhibitors, Oncology (self-administered), etc. — Each helps select patients per product labeling/guidelines and dosing
See Part 2 for remainder of alphabetized list

What providers must do

Prior Authorization

Prior authorization required for listed target drugs

Drugs listed under each program/category are subject to the plan's Prior Authorization or Specialty Prior Authorization program; prescribers must request prior authorization per the program before coverage is allowed.

Documentation Required

Prescriber documentation requirement for combination agents and alternative dosage forms

For certain combination agents and alternative dosage forms, the prescriber must provide documentation that individual ingredients or oral solid dosage forms are not clinically appropriate when required by the program intent.

Codes and coding notes

This part contains no specific code groups (NDC/CPT/HCPCS) or explicit coverage-status code tables. Providers should reference the member benefit materials or the policy's other parts and contact the number on the member ID card (or 800-285-9426) for code-level billing and coverage guidance.

Background and other notable information

Program intent: these prior authorization and step therapy programs are designed to align drug use with product labeling and clinical guidelines and to encourage safe, clinically appropriate, and cost-effective prescribing.

Summary of changes/clarifications: this part (a) enumerates program categories and their target drugs with one-sentence program intents, (b) does not include clinical criteria or numeric thresholds in this part, and (c) notes that a manufacturer discontinued a product in early 2024 (informational).

Document changes

clarified

Enumerates numerous prior authorization and specialty prior authorization program categories with their target drugs and high-level program intents.

clarified

addedLatest

Notes that a manufacturer discontinued a product in early 2024.

Operational metadata

Header metadata

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrior Authorization/Step Therapy Program drug list (partial)

Policy NumberN/A

Effective Date

Last Review

Next Review

StatusCURRENT