Prior Authorization Drug List
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This document lists drugs and supplies that require prior authorization from Blue KC for coverage; it affects providers and pharmacy/benefit management staff who submit prior authorization requests for members under Blue KC plans.
No material clinical or coverage changes in this revision.
Items Requiring Prior Authorization
Items Requiring Prior Authorization
The document lists drugs and supplies that require prior authorization. No approval criteria, limitations, or exceptions are provided in this policy.
Examples (partial list)
- Abiraterone acetate (Code Type = Prior Authorization)
- Actemra (Tocilizumab) (Code Type = Prior Authorization)
- Actimmune (Interferon gamma-1b) (Code Type = Prior Authorization)
- Adalimumab-adbm (Code Type = Prior Authorization)
- Adbry (Tralokinumab-ldrm) (Code Type = Prior Authorization)
- Adcetris (Brentuximab vedotin) (Code Type = Prior Authorization)
- Adempas (Riociguat) (Code Type = Prior Authorization)
- Aimovig (Erenumab-aooe) (Code Type = Prior Authorization)
- Ajovy (Fremanezumab-vfrm) (Code Type = Prior Authorization)
- Albendazole (Code Type = Prior Authorization)
- Alecensa (Alectinib HCl) (Code Type = Prior Authorization)
- Alosetron hydrochloride (Code Type = Prior Authorization)
- Alyq (Tadalafil (Pulmonary Hypertension)) (Code Type = Prior Authorization)
- Ambrisentan (Code Type = Prior Authorization)
- Amjevita (Adalimumab-atto) (Code Type = Prior Authorization)
- Apomorphine hydrochloride (Code Type = Prior Authorization)
- Aranesp albumin free (Darbepoetin alfa) (Code Type = Prior Authorization)
- Armodafinil (Code Type = Prior Authorization)
- Avonex (Interferon beta-1a) (Code Type = Prior Authorization)
- Avsola (Infliximab-axxq) (Code Type = Prior Authorization)
- Bafiertam (Monomethyl fumarate) (Code Type = Prior Authorization)
- Beleodaq (Belinostat) (Code Type = Prior Authorization)
- Belsomra (Suvorexant) (Code Type = Prior Authorization)
- Benlysta (Belimumab) (Code Type = Prior Authorization)
- Betaseron (Interferon beta-1b) (Code Type = Prior Authorization)
- Bexarotene (Code Type = Prior Authorization)
Coding / Billing Entries
| No codes listed |
Prior Authorization Drug List — Provider Actions
Prior Authorization Required
Prior Authorization is required for the drugs and biologicals listed below. Providers must obtain prior authorization before submitting claims for these products. Failure to secure prior authorization may result in claim denial or delay. To request authorization, follow payer-specific submission procedures and include all required clinical documentation supporting medical necessity.
- ABIRATERONE ACETATE (ABIRATERONE ACETATE)
- ACTEMRA (TOCILIZUMAB)
- ACTIMMUNE (INTERFERON GAMMA-1B)
- ADALIMUMAB-ADBM (ADALIMUMAB-ADBM)
- ADBRY (TRALOKINUMAB-LDRM)
- ADCETRIS (BRENTUXIMAB VEDOTIN)
- ADEMPAS (RIOCIGUAT)
- AIMOVIG (ERENUMAB-AOOE)
- AJOVY (FREMANEZUMAB-VFRM)
- ALBENDAZOLE (ALBENDAZOLE)
- ALECENSA (ALECTINIB HCL)
- ALOSETRON HYDROCHLORIDE (ALOSETRON HCL)
- ALYQ (TADALAFIL (PULMONARY HYPERTENSION))
- AMBRISENTAN (AMBRISENTAN)
- AMJEVITA (ADALIMUMAB-ATTO)
- APOMORPHINE HYDROCHLORIDE (APOMORPHINE HYDROCHLORIDE)
- ARANESP ALBUMIN FREE (DARBEPOETIN ALFA)
- ARMODAFINIL (ARMODAFINIL)
- AVONEX (INTERFERON BETA-1A)
- AVSOLA (INFLIXIMAB-AXXQ)
- BAFIERTAM (MONOMETHYL FUMARATE)
- BELEODAQ (BELINOSTAT)
- BELSOMRA (SUVOREXANT)
- BENLYSTA (BELIMUMAB)
- BETASERON (INTERFERON BETA-1B)
- BEXAROTENE
Key Definitions
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