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Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

Walgreens Information:

Walgreens is not part of Blue Cross of Idaho's network of pharmacies for our under-65 members who have pharmacy benefits managed by CVS Caremark. Blue Cross of Idaho made this decision as part of our continuing efforts to hold down the cost of healthcare.

To obtain an accurate listing of the network pharmacies in your area, please log in as a member and click the link "Pharmacy Benefits" then select "Find a pharmacy" located under the "Order Prescriptions" menu. If you are not yet registered as a member, please click here to register as a member.

Walgreens is a part of our network of pharmacies for Medicare Advantage members. Medicare Advantage members please call customer service at 1-888-494-2583 or TTY 1-800-377-1363 to find a pharmacy near you.

Drugs Requiring Prior Authorization

All medications being used for an off-label indication must have prior authorization.

The following drugs and/or drug classes require prior authorization. All requests for coverage of these drugs must be referred to Blue Cross of Idaho`s Pharmacy Management Department. Please have your doctor complete the Pharmacy Prior Authorization Form and fax to (208) 387-6969.

Medical Policies address other drug/drug classes which may or may not be listed below. From this website, please enter the name or drug class in the upper right hand search box to find out if it is referenced in a Medical Policy. You may need to perform your search by the brand name, generic name and/or drug class. If a medical policy exists for that drug, the search engine will locate it. Some of the drugs listed below are also linked to Medical Policies. To access these Medical Policies, just click the link on the drug name.

Group contracts, Medicare Advantage plans, Medicare supplement plans, individual policies (e.g. Personal Blue, HSA Blue and Essential Blue products) that do not have specific pharmacy benefits may have additional prior authorization requirements. If you have questions regarding this matter, please contact our Customer Services Department using the contact information provided on the back of the member's ID card.

(Direct Link to Medicare Part B Prior Authorization Drugs)

(Direct Link to Medicare Part D Drug Benefits)

This is not an all-inclusive list and is subject to change.

Updated: November 2013

 

Drug Class Section: NOTE: Individual drug names not listed here.

ALL OUTPATIENT INTRAVENOUS THERAPY
REQUIRES PRIOR AUTHORIZATION


Contraceptives (ALL FORMS if coverage of birth control is  excluded)
Enteral Formula and Supplies
Factor
Growth Hormone
Immune Globulin (IgG)
Implantable Hormone Pellets
Intra-articular Hyaluronan Injections
Intrathecal Medications, Pumps and Supplies
Intravenous Iron
Intravenous Antibiotics, Antivirals and Antifungals

 

________________________________________________


Individual Drug Name Section:

If drug names not listed here see also drug class section above.


Abstral (fentanyl sublingual tablets) PA form & Guidelines
Actemra (tocilizumab)
Adcetris (brentuximab vedotin)
Adcirca (tadalafil)
Adempas (riociguat)
Afinitor (everolimus)
Aldurazyme (laronidase)
Amevive (alefacept)
Aralast (alpha-1-proteinase inhibitor)
Arranon (nelarabine)
Arzerra (ofatumumab)
Aubagio (teriflunamide)
Avastin (bevacizumab)
Benlysta (belimumab)
Berinert (human C1 inhibitor)
Betaseron (interferon beta-1b) Step Therapy guidelines 
Boniva IV (ibandronate)
Bosulif (bosutinib)
Botox (botulinum toxin type A)
Buphenyl (sodium phenylbutyrate)
Byetta (exenatide)
 PA formGuidelines 

Bydureon (exenatide ER) PA form & Guidelines
Caprelsa (vandetanib)

Celebrex (celecoxib), see COX-2 info
Ceredase (alglucerase)
Cerezyme (imiglucerase) 
 
Cimzia (certolizumab)
Cinryze (c1 esterase inhibitor)
Cometriq (cabozantinib)

Dificid (fidaxomicin)

Dysport (abobotulinumtoxinA)
Elaprase (idursulfase)
Elelyso (taliglucerase alfa)
Eliquis (apixaban)
 
 

Enbrel (etanercept)
Erwinaze (asparaginase)

Euflexxa (intra-articular Hyaluronan Injection)

Extavia (interferon Beta-1b) Step Therapy guidelines 

Fabrazyme (agalsidase beta) 

Fentora (fentanyl buccal tablet) PA form & Guidelines
Firazyr (icatibant injection)
Fludara (fludarabine)

Folotyn (pralatrexate)

Forteo (teriparatide)
Fycompa (perampanel)
Gazyva (obinutuzumab)

Gel-One (intra-articular Hyaluronan Injection)
Gilenya (fingolimod) Guidelines

Gleevec (imatinib mesylate) 
Halaven (eribulin)

Humira (adalimumab)

Hyalgan (intra-articular Hyaluronan Injection) 

Ilaris (canakinumab)
Imbruvica (ibrutinib)

Implanon (etonagestrel)

Incivek (telaprevir)

Inlyta (axitinib)

Iressa (gefitinib)
Istodax (romidepsin)

Ixempra (ixabepilone)
Jakafi (ruxolitinib)
Jetrea (ocriplasmin)

Jevtana (cabazitaxel)
Kadcyla (ado-trastuzumab emtansine)

Kalbitor (ecallantide)

Kalydeco (ivacaftor)

Kineret (anakinra)
Korlym (mifepristone)
Krystexxa (pegloticase)
Kyprolis (carfilzomib) 

Leustatin (cladribine)

Lovenox (enoxaparin sodium)
Lumizyme (alglucosidase alfa)
Lupron Depot (leuprolide acetate)
Mekinist (trametinib)
Myobloc (botulinum toxin type B) 























Myozyme (alglucosidase alfa)
Naglazyme (galsulfase) 

Nexavar (sorafenib)
 

Nplate (romiplostim)

Nulojix (belatacept)
Olysio (simprevir)

Onfi (clobazam)
Opsumit (macitentan)
Orencia (abatacept)

Orthovisc (intra-articular Hyaluronan Injection)
Perjeta (pertuzumab) 
 

Prialt (ziconotide)

Prolastin (alpha-1-proteinase inhibitor)
Prolia (denosumab)
Promacta (eltrombopag)
Pomalyst (pomalidomide)
Provenge (sipuleucel-T) 

Reclast (zoledronic acid)

Regranex (becaplermin) 

Remicade (infliximab) 

Revatio (sildenafil)
Revlimid (lenalidomide)

Rituxan (rituximab)
Sandostatin LAR (octreotide prolonged release) 

Signifor (pasireotide)
Simponi (golimumab)

Sirturo (bedaquiline)
Somatuline (lanreotide)

Soliris (eculizumab)

Sovaldi (sofosbuvir)
Sprycel (dasatinib)

Stelara (ustekinumab)
Stivarga (regorafenib)

Supartz (intra-articular Hyaluronan Injection)
Supprelin LA (histrelin acetate)

Sutent (sunitinib malate)
Sylatron kit (peginterferon alfa-2b) 

Synagis (palivizumab) 

Synribo (omacetaxine mepesuccinate)
Synvisc (intra-articular Hyaluronan Injection)

Synvisc-One (intra-articular Hyaluronan Injection)
Tafinlar (dabrafenib)

Tarceva (erlotinib)

Tasigna (nilotinib)
Tecfidera (dimethyl fumerate)

Temodar (temozolomide)

Thalomid (thalidomide)

Torisel (temsirolimus)

Treanda (bendamustine)
Truvada (emtricitabine and tenofovir)

Tykerb (lapatinib)

Tysabri (natalizumab)
Tyvaso (treprostinil nebulizer solution)

Valchlor (mechlorethamine) 

Velcade (bortezomib)

Ventavis (iloprost)

Victoza (liraglutide) PA form & Guidelines
Victrelis (boceprevir)

Vivaglobin (subcutaneous IVIG)
Voraxaze (glucarpidase)
Votrient (pazopanib)
Vpriv (velaglucerase alfa)
Xeljanz (tofacitinib)

Xeloda (capecitabine)
Xeomin (incobotulinumtoxina)

Xgeva (denosumab)
Xiaflex (clostridial collagenase) 

Xolair (omalizumab) PA form
Xtandi (enzalutamide)

Yervoy (ipilimumab)
Zaltrap (ziv-aflibercept)
Zelboraf (vemurafenib)

Zemaira (alpha-1-proteinase inhibitor)

Zolinza (vorinostat)

Zortress (everolimus)
Zytiga (abiraterone acetate)