CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Prior Authorization Programs for Members on the Oklahoma Performance Full Drug List

Lists drug categories and specific prescription drugs on the Oklahoma Performance Full Drug List that are subject to prior authorization for Blue Cross Blue Shield - Oklahoma members. Affected parties include prescribing providers and pharmacy/benefit administrators.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrior Authorization Programs for Members on the Oklahoma Performance Full Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for prescriptions listed on the Oklahoma Performance Full Drug List via the number on the member ID card or bcbsok.com/provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks extracted

~200+listed drug names (approx.)

Multipletiered entries

1phone contact method

Provider Actions & Prior Authorization Requirements

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Prior Authorization

Prior Authorization Required

Prior Authorization Required — Coverage for the prescription drugs and drug categories listed on the Oklahoma Performance Full Drug List is subject to prior authorization. Providers must obtain prior authorization before dispensing or administering these medications when required by the member’s drug benefit plan.

Prior authorization applies to the drugs and categories enumerated on the Oklahoma Performance Full Drug List (examples include, but are not limited to, topical therapies for actinic keratosis; acute migraine agents; biologic immunomodulators; multiple oncology and specialty products).
Some drug categories use tiered/formulary groupings (e.g., entries showing "1 =" and "2 ="), indicating preferred and alternative placement; these groupings can affect prior authorization requirements and preferred step therapy.
Requests for medications not listed may require an exception review.
If prior authorization criteria are not met, the request may be denied; an exception review may be available but the member or provider may still need to meet specific program criteria for approval.

Documentation Required

Documentation Required for Prior Authorization

Documentation for Prior Authorization — When submitting a prior authorization request, include sufficient clinical information to support the medical necessity of the requested drug.

Include: drug name, dosage, intended indication, relevant prior therapies and responses, and any diagnostic or laboratory data that support the request.
If requesting an exception review for a drug not on the Drug List, provide supporting clinical rationale and documentation demonstrating why the preferred or listed alternatives are not appropriate for the member.

Note

How to Request Authorization

How to Request Authorization and Contact Information — To initiate a prior authorization or exception review, contact Blue Cross Blue Shield of Oklahoma using the member’s ID card number or the provider portal.

Call the number listed on the member’s ID card for prior authorization or questions.
Providers may also begin the prior authorization or exception review process at bcbsok.com/provider (or the current provider portal listed by the payer).
These programs are subject to change; third-party brand names are the property of their respective owners.

Denial Risk

Denial Risk and Exception Review

Denial Risk When Criteria Not Met — Requests may be denied if the submitted information does not meet the drug-specific prior authorization program criteria.

If denied, an exception review may be requested but approval is contingent on meeting the program criteria.
Ensure all required clinical documentation is provided at the time of request to reduce the likelihood of denial or delay.

Background

This section is a formulary-style listing of drug categories and specific prescription products on the Oklahoma Performance Full Drug List that are subject to prior authorization. The document enumerates numerous therapeutic classes and many individual agents (examples include topical agents for actinic keratosis such as diclofenac gel, classes like Biologic Immunomodulators, and multiple oncology and specialty agents shown with tier markers) and indicates which products require authorization before coverage is provided.

Entries are presented as categories with examples of included products; some categories show numbered subgrouping (for example, 1 = and 2 =) that reflect formulary positioning or tiering of preferred versus alternate agents. The listing does not include the detailed clinical criteria for each prior authorization program in these extracted excerpts, but it identifies the medicines and categories that fall under prior authorization requirements.

For questions or to begin an exception or prior authorization review, providers or members should use the contact information on the member's ID card or direct the prescribing provider to bcbsok.com/provider to start the review process.

Category / Group	1 = (preferred / tier 1)	2 = (alternative / tier 2)
Antifungals (formerly Antifungal Agents)
Brexafemme; Cresemba
Tolsura; Vfend (voriconazole); Vivjoa

Entry / Example	1 = (preferred / tier 1)	2 = (alternative / tier 2)
Calquence / related kinase inhibitors
Calquence; Caprelsa (in various listed pairings)
Qinlock; Retevmo; Pomalyst (appearing as alternate agents in the listings)

OpenPayer

Prior Authorization Programs for Members on the Oklahoma Performance Full Drug List

Provider Actions & Prior Authorization Requirements

Background

Step Therapy / Tiering Information