CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Prior Authorization/Step Therapy Program (drug list)

Defines prior authorization and step therapy programs for specified drugs and therapeutic classes, describing program intents and target drugs for Blue Cross Blue Shield - Oklahoma members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrior Authorization/Step Therapy Program (drug list)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed target drugs or confirm step therapy requirements with the member's benefit before prescribing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+therapy groups or target drug listings in this partial document

~80+distinct target drug entries shown in these chunks

Twoprogram types

Everyentries with Program Intent

Coverage Criteria and Program Intents

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Sequencing/step therapy criteria

Hepatitis C and biologic agent sequencing

Hepatitis C genotype preference: Use of the preferred agent by genotype is typically required before coverage of non-preferred products for Hepatitis C treatment.

Supports formulary sequencing based on genotype as stated in program intent.

Biologic immunomodulator sequencing: Encourages use of first-line agents and indication-preferred biologics prior to non-preferred biologic immunomodulators.

Applies to rheumatoid arthritis/psoriasis biologics; preferred agents by indication should be used before non-preferred biologics.

Coding and Target Drug Code Lists

Durable/Device productsmixed

Dexcom G6 CGM System	Continuous Glucose Monitor device listed as target product
Dexcom G7 CGM System	Continuous Glucose Monitor device listed as target product
Freestyle Libre	Continuous Glucose Monitor device listed as target product
Freestyle Libre 2	Continuous Glucose Monitor device listed as target product
Freestyle Libre 3	Continuous Glucose Monitor device listed as target product

Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis)mixedCovered

Adalimumab-aacf	biologic immunomodulator (listed)
Humira	biologic immunomodulator (listed)
Enbrel	biologic immunomodulator (listed)
Skyrizi	biologic immunomodulator (listed)

GLP-1 AgonistsmixedCovered

Bydureon Bcise	GLP-1 agonist (listed)
Ozempic	GLP-1 agonist (listed)
Mounjaro	GLP-1 agonist (listed)
Trulicity	GLP-1 agonist (listed)

Colony Stimulating Factors - Target Drugsmixed

Fylnetra	Listed colony stimulating factor product
Granix	Listed colony stimulating factor product
Neupogen	Listed colony stimulating factor product
Nypozi	Listed colony stimulating factor product
Nyvepria	Listed colony stimulating factor product
Releuko	Listed colony stimulating factor product
Rolvedon	Listed colony stimulating factor product
Ryzneuta	Listed colony stimulating factor product
Stimufend	Listed colony stimulating factor product
Udenyca	Listed colony stimulating factor product

1–10 of 11

1/2

DPP-4 Inhibitors and Combinations - Target Drugsmixed

Alogliptin	DPP-4 inhibitor target drug
Alogliptin-metformin	DPP-4 combination
Alogliptin-pioglitazone	DPP-4 combination
Brynovin	DPP-4 related target
Jentadueto	DPP-4 combination
Jentadueto XR	DPP-4 combination
Kombiglyze XR	DPP-4 combination
Nesina	DPP-4 inhibitor
Onglyza	DPP-4 inhibitor
Sitagliptin	DPP-4 inhibitor

1–10 of 16

1/2

Gabapentin ER - Target Drugsmixed

Gralise	Gabapentin ER target drug
Horizant	Gabapentin ER target drug

Glucose Test Strips - Target Drugsmixed

All non-preferred brand test strips and disks

Glucose test strips group

Infertility 1 - Target Drugsmixed

Chorionic Gonadotropin	Infertility target drug
Gonal F	Infertility target drug
Gonal F RFF	Infertility target drug
Novarel	Infertility target drug

Insomnia - Target Drugsmixed

Ambien	Insomnia target drug
Ambien CR	Insomnia target drug
Belsomra	Insomnia target drug
Dayvigo	Insomnia target drug
Edluar	Insomnia target drug
Lunesta	Insomnia target drug
Quviviq	Insomnia target drug
Rozerem	Insomnia target drug
Silenor	Insomnia target drug
Zolpidem	Insomnia target drug

Ophthalmic Prostaglandins - Target Drugsmixed

Iyuzeh	Ophthalmic prostaglandin target
Lumigan	Ophthalmic prostaglandin target
Omlonti	Ophthalmic prostaglandin target
Travatan Z	Ophthalmic prostaglandin target
Vyzulta	Ophthalmic prostaglandin target
Xalatan	Ophthalmic prostaglandin target
Xelpros	Ophthalmic prostaglandin target
Zioptan	Ophthalmic prostaglandin target

Oral Inhalers - Target Drugsmixed

Advair Diskus	Oral inhaler target drug
Alvesco	Oral inhaler target drug
Fluticasone furoate ellipta	Oral inhaler target drug
Fluticasone propionate aerosol inhalation	Oral inhaler target drug

Phosphate Binders - Target Drugsmixed

Auryxia	Phosphate binder target drug
Fosrenol/lanthanum carbonate	Phosphate binder target drug
Renagel	Phosphate binder target drug
Renvela	Phosphate binder target drug
Velphoro	Phosphate binder target drug

SGLT Inhibitors and Combinations - Target Drugsmixed

Brenzavvy/Bexagliflozin	SGLT inhibitor target drug
Inpefa	SGLT inhibitor or combo
Invokana	SGLT inhibitor
Invokamet	SGLT combination
Invokamet XR	SGLT combination
Qtern	SGLT combination
Segluromet	SGLT combination
Steglatro	SGLT inhibitor
Steglujan	SGLT combination

Topical NSAIDs - Target Drugsmixed

Flector	Topical NSAID target drug
Licart	Topical NSAID target drug
Pennsaid/diclofenac 2% solution	Topical NSAID target drug

Children age cutoff — <= 12 years

Children age cutoffDefined as members 12 years of age and under for purposes of the Alternative Dosage Form program (program is not applicable to children ≤ 12 years).

ApplicabilityApplies specifically to the Alternative Dosage Form prior authorization program which encourages use of oral solid dosage forms prior to alternative forms.

Documentation requirementPrescriber must document that the oral solid dosage form is not clinically appropriate for the patient when requesting an alternative dosage form.

Infertility step therapy exception — Does not apply to standard HMO plans

Infertility step therapy exceptionThe infertility step therapy program does not apply to standard HMO plans.

Affected categoryInfertility 1 step therapy (targets: Chorionic Gonadotropin, Gonal F, Gonal F RFF, Novarel).

Program intentEncourages use of formulary agent prior to non-formulary agents unless not clinically appropriate, per product labeling dosing—except for standard HMO plans where the step therapy does not apply.

Provider Actions, Prior Authorization, and Step Therapy Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the drug categories and specific agents listed in this section. Use of a listed target drug without prior authorization may result in denial of coverage.

Applies to the many target agents and therapeutic classes (see full list within this section).
Coverage is allowed only when prior authorization/step therapy criteria are met.

Step Therapy

Prior Authorization / Step Therapy Applies to Listed Categories

Prior authorization and/or step therapy requirements apply to the listed categories and agents. Step therapy may require trial and failure or contraindication to a formulary/preferred or first‑line agent before a non‑preferred or target agent will be approved.

Step therapy expectations: prescriber must document prior use of preferred/generic or formulary agents when required, or provide clinical rationale why those agents are inappropriate.
Applied categories include but are not limited to: Antidepressants, Atopic Dermatitis, Atypical Antipsychotics, Colony Stimulating Factors, DPP‑4 Inhibitors, Gabapentin ER, Insomnia agents, SGLT Inhibitors, and many others listed in this section.

Note

Plan‑Specific Coverage Verification Required

Prescribers must verify whether the patient’s specific pharmacy benefit includes the drug category or agent prior to submitting a request. Some categories apply only to certain plans; others may be excluded.

Refer to the member’s benefit materials or call the phone number on the member’s BCBS OK ID card.
Call 800-285-9426 to confirm the status of a particular drug and plan applicability.

Documentation Required

Clinical Support Required

Clinical documentation and supporting evidence are required with prior authorization requests. Clinical reviewers rely on product labeling, nationally recognized guidelines, compendia, and clinical studies when evaluating requests.

Include relevant diagnosis, prior treatment history, dosing information, and rationale for use.
When requesting alternative dosage forms, prescriber must document why the oral solid dosage form is not clinically appropriate (not required for children ≤12 years).

Step Therapy

Step Therapy Requirements for Specified Categories

Step therapy requirements for specific categories encourage use of formulary, preferred, or cost‑effective generic/first‑line agents prior to non‑preferred or higher‑cost agents, unless not clinically appropriate.

Examples: Antidepressants — encourage preferred generic agents for new prescriptions before brand agents; Atopic Dermatitis — require topical corticosteroid prior to Elidel/Eucrisa/tacrolimus unless not appropriate; Colony Stimulating Factors — use formulary agent prior to non‑formulary agents.
Exceptions: clinical contraindication, intolerance, or other documented clinical rationale may exempt a patient from step requirements.

Definitions and Key Terms

Children — Defined as members 12 years of age and under for Alternative Dosage Form applicability

Definition (Children)For Alternative Dosage Form applicability, 'Children' are defined as members 12 years of age and under; the Alternative Dosage Form program is not applicable to these members.

Program linkageThis definition is used specifically within the Alternative Dosage Form prior authorization entry to determine applicability.

Clinical rationaleChildren often experience issues swallowing oral solid dosage forms, which is why the program excludes members ≤12 years from the requirement to try oral solids first.

Preferred agent by genotype — In Hepatitis C treatment, preferred agent selection is based on viral genotype

Preferred agent by genotypeIn Hepatitis C treatment, selection of the preferred agent is based on viral genotype and is typically required before coverage of non‑preferred products.

Program contextThis sequencing requirement is part of the Hepatitis C Direct Acting Antivirals prior authorization program intent to align therapy with product labeling and clinical guidelines.

Coverage sequencingUse of the preferred agent by genotype supports formulary sequencing prior to approval of non‑preferred agents, per product labeling dosing.

Step Therapy — Definition of step therapy as a utilization management approach

DefinitionStep therapy is a utilization management approach that encourages use of a formulary/preferred or cost‑effective generic agent before coverage of non‑formulary or non‑preferred agents, unless not clinically appropriate, following product labeling dosing.

Common requirementApplied across multiple categories (e.g., colony stimulating factors, DPP‑4 inhibitors, gabapentin ER, SGLT inhibitors, ophthalmic prostaglandins, oral inhalers, topical NSAIDs) to promote formulary agents first.

Exception clauseCoverage of non‑preferred agents may be allowed if the preferred/formulary agent is not clinically appropriate for the patient, per product labeling and clinical judgment.

Intended outcomeEncourage safe, cost‑effective medication use and alignment with product labeling, clinical guidelines, compendia, or clinical studies.

Step Therapy Tables and Rules

Step	Requirement	Applies to / Notes
1	Encourages use of first-line agents and preferred products (by indication or genotype) before non-preferred or target agents.	Applies to biologic immunomodulators (rheumatoid arthritis/psoriasis) and hepatitis C direct-acting antivirals where preferred agent selection may be based on indication or viral genotype; dosing per product labeling.

Step	Requirement	Applies to / Notes
1	Use of preferred/generic/formulary agent is encouraged before nonpreferred/brand products; use cost‑effective generic or preferred agent first unless not clinically appropriate.	Applies to antidepressants, atypical antipsychotics, atopic dermatitis topicals, colony stimulating factors, DPP‑4 inhibitors, gabapentin ER, glucose test strips, insomnia agents, and other listed categories per program entries.

Step	Requirement	Applies to / Notes
1	Use preferred/formulary or cost‑effective generic agent before non‑preferred or non‑formulary agents for listed categories, unless not clinically appropriate; follow product labeling dosing.	Specifically listed categories include colony stimulating factors, DPP‑4 inhibitors and combinations, gabapentin ER, ophthalmic prostaglandins, oral inhalers, phosphate binders, SGLT inhibitors and combinations, topical NSAIDs, and others noted in program entries.

OpenPayer