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Medical Policies

5.0 Prescription Drug


5.01 Prescription Drugs Introduction
For Blue Cross of Idaho`s definition of medically necessary and investigational, please click here.
5.01.01 Guidelines for Prior Authorization of Pharmacologic Therapies
5.01.04 Erythropoiesis- Stimulating Agents (ESAs)
5.01.05 Botulinum Toxin
5.01.06 Human Growth Hormone
5.01.07 Acute and Maintenance Tocolysis
5.01.08 Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
5.01.09 Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension
5.01.10 Immune Prophylaxis for Respiratory Syncytial Virus
5.01.15 Infliximab
5.01.16 Intravenous Anesthetics for the Treatment of Chronic Pain
5.01.17 Repository Corticotropin Injection
5.01.19 Injectable Clostridial Collagenase for Firbroproliferative Disorders 
5.01.21 Newer Oral Anticoagulants
5.01.23 Testosterone Replacement Therapies
5.01.25 Direct Acting Antiviral Medications for Treatment of Hepatitis C
5.01.93 Specialty Drugs
5.01.95 Xolair (Omalizumab)
5.01.96 Therapeutically Generic Override
5.01.100 Treatment of Inflammatory Bowel Diseases with Biologic-Response Modifiers
5.01.101 Enzyme-replacement Therapy for Lysosomal Storage Disorders
5.01.105 IV Iron Therapy
5.01.108 Pharmacological Treatment of Hereditary Angioedema
5.01.109 Implantable Hormone Pellets
5.01.110 Belimumab (Benlysta®)
5.01.111 Eculizumab (Soliris)
5.01.112 Use of Sodium Oxybate (Xyrem®)
5.01.150 Pharmacologic Compounds

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